HARVARD MEDICAL Improving Sleep - A Guide To A Good Nights Rest PDF

A Harvard Medical School Special Health Report
Improving Sleep
A guide to a good nights rest
In this report:
Diagnosing sleep
problems
Practical tips for
sounder sleep
Sleep apnea solutions
Special Bonus Section
Dangers of sleep
deprivation
Price: $26
This Harvard Health Publication was prepared exclusively for Helen McIntosh - Purchased at http://www.health.harvard.edu/
Harvard Health Publications
Copyright Notice
This report is copyrighted by Harvard University and is protected by
U.S. and international copyright. All rights reserved.
Heres what you CAN do

Print out one copy and route this original
to family.
You are permitted to have one copy of this
publication on your computer at any time
(you cant put it on a network unless you purchased a license to do so). If you have paid
for more copies, then you may have that many
copies on computers at any time.
Copy, on an occasional basis, a couple of
pages to give to friends, family members,
or colleagues.
We are registered with the Copyright Clearance Center (CCC). You can comply with the
copyright laws by paying a royalty on copies
you make of passages. But not even the CCC
can authorize cover-to-cover photocopying
or wholesale electronic forwarding.
If you want to distribute copies of this
publication, either in print or electronic form,
to others on a regular basis, ask us about bulk
discounts or licensing opportunities. You may
be able to negotiate an agreement, for a single
fee, that would enable you to legally distribute
photocopies or electronic copies to others.
Heres what you CANT do

(without prior permission)
Make or forward e-mail copies of an entire
publication. The law provides for a very limited
amount of copying, commonly referred to as
fair use. However, cover-to-cover photocopy
ing is forbidden.
Electronic transmission of a copyrighted work is
the legal equivalent of photocopying it (and so
is posting it on the Internet or in an electronic
database), and is therefore not allowed.
Routinely copy and distribute portions.

Republish or repackage the contents.
Some publishers must resort to lawsuits to protect
their publications. Harvard Health Publications
would like to eliminate the need for such suits by
helping to educate customers. We hope this outline
has helped explain what is legal, and what is not.
For more information

Copyright Clearance Center
Telephone: 508-750-8400
www.copyright.com
Permissions Requests
Dawn Scott, Harvard Health Publications
dawn_scott@hms.harvard.edu
Telephone: 617-432-4714
Licensing and Corporate Sales

Jennifer Mitchell,
Staywell Consumer Health Publishing
jmitchell@staywell.com
Telephone: 203-541-3887
www.harvardhealthcontent.com
Bulk Sales
Tonya Phillips,
Staywell Consumer Health Publishing
tphillips@staywell.com
Telephone: 888-456-1222 x31110 (toll-free)

Harvard Medical School
10 Shattuck Street, 2nd Floor
Boston, MA 02115-6011 U.S.A.
www.health.harvard.edu
improving sleep
SPECIAL HEALTH REPORT
Medical Editor
Lawrence Epstein, M.D.
Instructor in Medicine, Harvard Medical School
Division of Sleep Medicine,
Brigham and Womens Hospital
Medical Director, SleepHealth Centers,
Brighton, Mass.
Contents
Sleep mechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Quiet sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dreaming (REM) sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sleep architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your internal clock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
3
4
4
Sleep throughout life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Editor
Julie Corliss
Editor, Special Health Reports
Kathleen Cahill Allison
special bonus section:

Dangers of sleep deprivation . . . . . . . . . . . . . . . . . . . . . . . 9
Art Director
Heather Derocher
General ways to improve sleep. . . . . . . . . . . . . . . . . . . . . 14
Production Editors
Mary Kenda Allen
Melissa Rico
Illustrator
Scott Leighton
Michael Linkinhoker
Published by Harvard Medical School
Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director
Copyright 2010 by Harvard University. Written permission is
required to reproduce, in any manner, in whole or in part, the
material contained herein. Submit reprint requests in writing to:
First-line strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Medical conditions and sleep problems. . . . . . . . . . . . . . 16

Illnesses that affect sleep. . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Types of insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
First-line treatment: Behavioral changes. . . . . . . . . . . . . . . . . .
Prescription medications for insomnia . . . . . . . . . . . . . . . . . .
Over-the-counter sleep aids. . . . . . . . . . . . . . . . . . . . . . . . . . .
20
20
22
25
Breathing disorders in sleep. . . . . . . . . . . . . . . . . . . . . . . 27

10 Shattuck St., 2nd Floor, Boston, MA 02115
617-432-1485 Fax: 617-432-4719
Snoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Sleep apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Web Site
Movement disorders and parasomnias. . . . . . . . . . . . . . . 33
For the latest information and most up-to-date publication

list, visit us online at www.health.harvard.edu.
Customer Service
Movement disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Parasomnias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
For all subscription questions or problems (rates, subscribing, address changes, billing problems) call 877-649-9457,
send an e-mail to HarvardProd@StrategicFulfillment.com,
or write to Harvard Health Publications, P.O. Box 9308,
Big Sandy, TX 75755-9308.
Narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Ordering Special Health Reports
Disturbances of sleep timing. . . . . . . . . . . . . . . . . . . . . . . 40
For multiple-copy discount rates, please write or call:

StayWell Consumer Health Publishing, Attn: SR Bulk Orders,
One Atlantic Street, Suite 604, Stamford, CT 06901
203-653-6270 (toll-free: 888-456-1222, ext. 31110).
Delayed sleep phase syndrome. . . . . . . . . . . . . . . . . . . . . . . .

Advanced sleep phase syndrome. . . . . . . . . . . . . . . . . . . . . . .
Jet lag. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sunday insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Shift work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Seasonal affective disorder. . . . . . . . . . . . . . . . . . . . . . . . . . .
For corporate sales and licensing, please e-mail:

jmitchell @ staywell.com.
Evaluation of sleep disturbances . . . . . . . . . . . . . . . . . . . 43
Harvard Medical School publishes Special Health Reports

on a wide range of topics. To order copies of this or other
reports, please see the instructions at the back of this
report, or go to our Web site: www.health.harvard.edu.
ISBN 978-1-935555-18-6
The goal of materials provided by Harvard Health Publications
is to interpret medical information for the general reader. This
report is not intended as a substitute for personal medical
advice, which should be obtained directly from a physician.
Symptoms of narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Treatments for narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
40
40
40
41
41
42
When to seek help. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Sleep laboratory evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Home-based tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
The benefits of good sleep . . . . . . . . . . . . . . . . . . . . . . . . 47

Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Dear Reader,
How do you feel when you wake up in the morning? Are you refreshed and ready to go, or
groggy and grumpy? For many people, the second scenario is all too common. Sleep-related
problems affect 50 million to 70 million Americans of all ages. Insomniatrouble falling or
staying asleepis the most common complaint, but other chronic disorders, including sleep
apnea, restless legs syndrome, or narcolepsy, can also contribute to a shut-eye shortfall. And
some people simply stay up too lateusually because theyre watching late-night TV,
according to a national time-use survey of more than 21,000 adults. Logging long hours on
the computer is another common cause of sleep loss.
Regardless of the reason, one in five Americans sleep less than six hours a nighta trend that
can have serious personal and public health consequences. Insufficient sleep can make you
too tired to work efficiently, to exercise, or to eat healthfully. Over time, sleep deprivation
increases the risk for a number of chronic health problems, including obesity, diabetes, and
heart disease (see Special Section: Dangers of sleep deprivation, page 9).
Whats more, 54% of American adultsas many as 110 million licensed drivershave driven
when drowsy at least once in the past year. Drowsy driving is one of the most common causes
of crashes in all modes of transportation, resulting in 8,000 deaths and 60,000 debilitating
injuries each year.
Even though many people acknowledge that sleep is important, few seek treatment for their
sleep problems. If you arent getting your share of sleep, you neednt fumble about in a fog
of fatigue. This report describes the complex nature of sleep and the latest in sleep research,
including the discovery of a genetic mutation that controls sleep duration. It also describes
the numerous health conditions and medications that can interfere with normal sleep, as well
as prescription and over-the-counter medications used to treat sleep disorders. Information
about the diagnosis and treatment of sleep apnea, an under-recognized yet life-threatening
sleep disorder, is also included. Most importantly, youll learn what you can do to get the
sleep you need for optimal health, safety, and well-being.
Sincerely,
Lawrence Epstein, M.D.

Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Sleep mechanics
or centuries, scientists scrutinized minute aspects

of human activity, but showed little interest in the
time that people spent in sleep. Sleep seemed inaccessible to medical probing and was perceived as an
unvarying period of inactivitya subject best suited
to poets and dream interpreters who could conjure meaning out of the void. All that changed in the
1930s, when scientists learned to place sensitive electrodes on the scalp and record the signals produced
by electrical activity in the brain. These brain waves
can be seen on an electroencephalogram, or EEG (see
Figure 1), which today is captured on a computer
screen. Since then, researchers have gradually come
to appreciate that sleep is a highly complex activity.
Figure 1 EEG brain wave patterns during sleep

Alpha waves
Relaxed wakefulness
Stage N1
Theta waves
Stage N2
K-complex
Sleep spindles
Stage N3
Delta waves
REM or dreaming sleep
These brain waves, taken by electroencephalogram, are used by

sleep experts to identify the stages of sleep. Close your eyes and
your brain waves will look like the first band, relaxed wakefulness. Theta waves indicate stage N1 sleep. (The N designates
non-REM sleep.) Stage N2 sleep shows brief bursts of activity as
sleep spindles and K-complex waves. Deep sleep (stage N3) is
represented by large, slow delta waves.
Improving Sleep
Using electrodes to monitor sleepers eye movements,

muscle tone, and brain wave patterns, they identified
several discrete stages of sleep. And today, researchers
continue to learn how certain stages of sleep help to
maintain health, growth, and functioning.
Scientists divide sleep into two major types: rapid
eye movement (REM) sleep or dreaming sleep, and
non-REM or quiet sleep. Surprisingly, they are as different from each other as either is from waking.
Quiet sleep
Sleep specialists have called non-REM or quiet sleep

an idling brain in a movable body. During this phase,
thinking and most physiological activities slow down,
but movement can still occur, and a person often shifts
position while sinking into deeper stages of sleep.
To an extent, the convention of describing people dropping into sleep actually parallels changes in
brain wave patterns at the onset of non-REM sleep.
When you are awake, billions of brain cells receive and
analyze sensory information, coordinate behavior,
and maintain bodily functions by sending electrical
impulses to one another. If youre fully awake, the EEG
will record a messy, irregular scribble of activity. Once
your eyes are closed and your nerve cells no longer
receive visual input, brain waves settle into a steady
and rhythmic pattern of about 10 cycles per second.
This is the alpha-wave pattern, characteristic of calm,
relaxed wakefulness.
The transition to quiet sleep is a quick one that
might be likened to flipping a switchthat is, you are
either awake (switch on) or asleep (switch off), according to research. Some brain centers and pathways stimulate the entire brain to wakefulness; others promote
falling asleep. One chemical, hypocretin, seems to play
an important role in regulating when the flip between
states occurs and keeping you in the new state. Interestingly, people with narcolepsy (see page 38) often
www.health.har vard.edu
lack hypocretin, and they consequently flip back and

forth between sleep and wakefulness frequently.
Three stages of quiet sleep

Unless something disturbs the process, you will proceed
smoothly through the three stages of quiet sleep.
Stage N1. In making the transition from wakefulness into light sleep, you spend about five minutes
in stage N1 sleep. On the EEG, the predominant brain
waves slow to four to seven cycles per second, a pattern called theta waves. Body temperature begins to
drop, muscles relax, and eyes often move slowly from
side to side. People in stage N1 sleep lose awareness
of their surroundings, but they are easily jarred awake.
However, not everyone experiences stage N1 sleep in
the same way: if awakened, one person might recall
being drowsy, while another might describe having
been asleep.
Stage N2. This first stage of true sleep lasts 10 to
25 minutes. Your eyes are still, and your heart rate and
breathing are slower than when awake. Your brains
electrical activity is irregular. Large, slow waves intermingle with brief bursts of activity called sleep spindles, when brain waves speed up for roughly half a
second or longer. The EEG tracings also show a pattern called a K-complex, which scientists think represents a sort of built-in vigilance system that keeps you
poised to awaken if necessary. K-complexes can also be
provoked by certain sounds or other external or internal stimuli. Whisper someones name during stage N2
sleep, and a K-complex will appear on the EEG. You
spend about half the night in stage N2 sleep.
Stage N3. Eventually, large, slow brain waves
called delta waves become a major feature on the EEG.
This is stage N3, known as deep sleep or slow-wave
sleep. During this stage, breathing becomes more regular. Blood pressure falls, and pulse rate slows to about
20% to 30% below the waking rate. The brain becomes
less responsive to external stimuli, making it difficult
to wake the sleeper.
Slow-wave sleep seems to be a time for your body
to renew and repair itself. Blood flow is directed less
toward your brain, which cools measurably. At the
beginning of this stage, the pituitary gland releases a
pulse of growth hormone that stimulates tissue growth
www.h e a l t h . h a r v a r d . e d u
and muscle repair. Researchers have also detected

increased blood levels of substances that activate your
immune system, raising the possibility that slow-wave
sleep helps the body defend itself against infection.
Normally, young people spend about 20% of their
sleep time in stretches of slow-wave sleep lasting up
to half an hour, but slow-wave sleep is nearly absent
in most people over age 65 (see The later years, page
8). Someone whose slow-wave sleep is restricted will
wake up feeling less refreshed. When a sleep-deprived
person gets some sleep, he or she will pass quickly
through the lighter sleep stages into the deeper stages
and spend a greater proportion of sleep time there,
suggesting that slow-wave sleep fills an essential role
in a persons optimal functioning.
Dreaming (REM) sleep
Dreaming occurs during REM sleep, which has been

described as an active brain in a paralyzed body.
Your brain races, thinking and dreaming, as your eyes
dart back and forth rapidly behind closed lids. Your
body temperature rises. Your blood pressure increases,
and your heart rate and breathing speed up to daytime
levels. The sympathetic nervous system, which creates
the fight-or-flight response, is twice as active as when
youre awake. Despite all this activity, your body hardly
moves, except for intermittent twitches; muscles not
needed for breathing or eye movement are quiet.
Just as slow-wave sleep restores your body, scientists believe that REM or dreaming sleep restores your
mind, perhaps in part by helping clear out irrelevant
information. Studies of students ability to solve a complex puzzle involving abstract shapes suggest the brain
processes information overnight; students who got a
good nights sleep after seeing the puzzle fared much
better than those asked to solve the puzzle immediately. Earlier studies found that REM sleep facilitates
learning and memory. People tested to measure how
well they had learned a new task improved their scores
after a nights sleep. If they were prevented from having REM sleep, the improvements were lost. On the
other hand, if they were awakened an equal number
of times from slow-wave sleep, the improvements in
the scores were unaffected. These findings may help
Improving Sleep
Your internal clock
Figure 2 Sleep architecture
Sleep stage
Awake
REM
N1
N2
N3
Hours of sleep
When experts chart sleep stages on a hypnogram, the different

levels resemble a drawing of a city skyline. This pattern is known
as sleep architecture. The hypnogram above shows a typical
nights sleep of a healthy young adult.
explain why students who stay up all night cramming

for an examination generally retain less information
than classmates who get some sleep.
About three to five times a night, or about every
90 minutes, a sleeper enters REM sleep. The first such
episode usually lasts only for a few minutes, but REM
time increases progressively over the course of the night.
The final period of REM sleep may last a half-hour. Altogether, REM sleep makes up about 25% of total sleep
in young adults. If someone who has been deprived of
REM sleep is left undisturbed for a night, he or she enters
this stage earlier and spends a higher proportion of sleep
time in ita phenomenon called REM rebound.
Sleep architecture
During the night, a normal sleeper moves between

different sleep stages in a fairly predictable pattern,
alternating between REM and non-REM sleep. When
these stages are charted on a diagram, called a hypnogram (see Figure 2), the different levels resemble a
drawing of a city skyline. Sleep experts call this pattern sleep architecture.
In a young adult, normal sleep architecture usually
consists of four or five alternating non-REM and REM
periods. Most deep sleep occurs in the first half of the
night. As the night progresses, periods of REM sleep
get longer and alternate with stage N2 sleep. Later in
life, the sleep skyline will change, with less stage N3
sleep, more stage N1 sleep, and more awakenings.
4
Improving Sleep
Certain brain structures and chemicals produce the states

of sleeping and waking. For instance, a pacemaker-like
mechanism in the brain regulates circadian rhythm.
(Circadian means about a day.) This internal clock,
which gradually becomes established during the first
months of life, controls the daily ups and downs of
biological patterns, including body temperature, blood
pressure, and the release of hormones.
The circadian rhythm makes peoples desire for
sleep strongest between midnight and dawn, and to a
lesser extent in midafternoon. In one study, researchers instructed a group of people to try to stay awake
for 24 hours. Not surprisingly, many slipped into naps
despite their best efforts not to. When the investigators
plotted the times when unplanned naps occurred, they
found peaks between 2 a.m. and 4 a.m. and between
2 p.m. and 3 p.m.
Most Americans sleep during the night as dictated
by their circadian rhythms, although many who work
on weekdays nap in the afternoon on the weekends. In
societies where taking a siesta is the norm, people can
respond to their bodies daily dips in alertness with a
one- to two-hour afternoon nap during the workday
and a correspondingly shorter sleep at night.
Figure 3 The sleep/wake control center

Thalamus
Hypothalamus
Suprachiasmatic
nucleus
Cerebellum
Brain stem
The pacemaker-like mechanism in your brain that regulates the

circadian rhythm of sleeping and waking is thought to be located
in the suprachiasmatic nucleus. This cluster of cells is part of the
hypothalamus, the brain center that regulates appetite, body
temperature, and other biological states.
Mechanisms of your sleep clock

In the 1970s, studies in rats identified the suprachiasmatic nucleus as the location of the internal clock.
This cluster of cells is part of the hypothalamus, the
brain center that regulates appetite and other biological states (see Figure 3). When this tiny area was damaged, the sleep/wake rhythm disappeared and the rats
no longer slept on a normal schedule. Although the
clock is largely self-regulating, its location allows it to
respond to several types of external cues to keep it set
at 24 hours. Scientists call these cues zeitgebers, a
German word meaning time givers.
Light. Light striking your eyes is the most influential zeitgeber. When researchers invited volunteers
into the laboratory and exposed them to light at intervals
that were at odds with the outside world, the participants
unconsciously reset their biological clocks to match the
new light input. The circadian rhythm disturbances and
sleep problems that affect up to 90% of blind people demonstrate the importance of light to sleep/wake patterns.
Time. As a person reads clocks, follows work and
train schedules, and demands that the body remain
alert for certain tasks and social events, there is cognitive pressure to stay on schedule.
Melatonin. Cells in the suprachiasmatic nucleus
contain receptors for melatonin, a hormone produced in
a predictable daily rhythm by the pineal gland, which is

located deep in the brain between the two hemispheres.
Levels of melatonin begin climbing after dark and ebb
after dawn. The hormone induces drowsiness in some
people, and scientists believe its daily light-sensitive
cycles help keep the sleep/wake cycle on track.
Your clocks hour hand

As the circadian rhythm counts off the days, another part
of the brain acts like the hour hand on a watch. This timekeeper resides in a nugget of nerve cells within the brain
stem, the area that controls breathing, blood pressure, and
heartbeat. Fluctuating activity in the nerve cells and the
chemical messengers they produce seem to coordinate
the timing of wakefulness, arousal, and the 90-minute
changeover between REM and non-REM sleep.
Several neurotransmitters (brain chemicals that
neurons release to communicate with adjacent cells)
play a role in arousal. Their actions help explain why
medications that mimic or counteract their effects can
influence sleep. Adenosine and gamma-aminobutyric
acid are believed to promote sleep. Acetylcholine
regulates REM sleep. Norepinephrine, epinephrine,
dopamine, and hypocretin stimulate wakefulness. Individuals vary greatly in their natural levels of neurotransmitters and in their sensitivity to these chemicals.
Why do we dream?
Youve probably wondered whether your dreams serve any
purpose. What does it mean when you arrive at your senior
prom in overalls, or when youre chased through the streets
of Paris by a giant turtle?
Those who have studied dreaming fall into two general
camps: those who say yes, dreams are significant, and those
who say no, theyre not.
Followers of the first camp trace many of their ideas to Sigmund Freud, who in 1900 proposed that dreams are meaningful representations of the unconscious mind in which
we reveal our hidden conflicts, desires, and fears, albeit in
disguised form. Post-Freudian theorists and psychoanalytic
thinkers subsequently elaborated on and refined his ideas, focusing on how dreams help the organization of thought and
the consolidation and reinforcement of long-term memory.
Other researchers, taking a physiological approach, are
skeptical. Pointing to studies from the 1970s showing that
dreams occur upon activation of neurotransmitters in a portion of the brain, they argue that dreams are merely aimless
and chaotic imagesessentially little more than the minds
attempt to make meaning out of the random chemical signals sent up from the brain stem. They also point out that we
only remember a minute percentage of our dreams; if they
were significant, surely wed remember them better.
Some research on the function of dreams has combined the
psychological and neurochemical approaches. One scientist,
for example, observed that patients who sustained injuries
and lesions in the brains frontal lobe no longer dreamed. This
suggests that dreaming involves areas in the front of the
brain that are connected to urges, impulses, and appetites.
Other research suggests that dreaming plays a role in helping
consolidate the days memories, attaching associations and
emotions and helping to retain important events. Further study
should offer important insights on why we dream and what
role, if any, our dreams can play in maintaining mental health.
Improving Sleep
Sleep throughout life
o a certain extent, heredity determines how people sleep throughout their lives. Identical twins,
for example, have much more similar sleep patterns
than nonidentical twins or other sibling pairs. Differences in sleeping and waking seem to be inborn,
although the genetic underpinnings arent fully
understood. But in 2009, scientists reported the discovery of a genetic mutation relating to sleep duration (see A gene that controls sleep length, below).
Nevertheless, many factors can affect how a person
sleeps. Aging is the most important influence on basic
sleep rhythmsfrom age 20 on, it takes progressively
longer to fall asleep. You sleep less each night, stages
N1 and N2 sleep increase, stage N3 sleep and REM
A gene that controls sleep length

Whether youre a night owl or an early riser, you probably
know roughly long you need to sleep to feel fully rested.
Some people feel perky after just seven hours of sleep,
while others are groggy if they log less than nine hours.
The discovery of a genetic mutation in two people who
need far less sleep than average helps explain at least
some of this variation.
Scientists found the mutation in a gene called DEC2,
which is known to affect circadian rhythms (see Your
internal clock, page 4). The mutations occurred in a
mother and daughter who were naturally short sleepers,
requiring just six hours a night instead of the average of
eight. Many Americans sleep just six hours nightly, but
most rely on alarms, caffeine, and power naps to awaken
and stay awake during the day. By contrast, these two
women awoke naturally after six hours.
The scientists then created genetically engineered mice
with the same mutation. The mice not only slept less
and stayed awake longer, they also needed less sleep to
recover following sleep deprivation. The finding, described
in a 2009 article in the journal Science, suggests the
potential to create a drug to enable humans to function
on less sleep. But experts say thats decades away, given
the still-undiscovered genes and other factors that control
the quantity and quality of sleep.
Improving Sleep
sleep decrease, and you awaken more often during

the night (see Table 1).
Childhood
For an adult to sleep like a baby is not only unrealistic

but also undesirable. A newborn may sleep eight times
a day, accumulating 18 hours of sleep and spending
about half of it in REM sleep. REM periods occur
more often, usually less than an hour apart.
At about the age of 4 weeks, a newborns sleep periods get longer. By 6 months, infants spend longer and
more regular periods in non-REM sleep; most begin
sleeping through the night and taking naps in the morning and afternoon. During the preschool years, daytime
naps gradually shorten, until by age 6 most children
are awake all day and sleep for about 10 hours a night.
Between age 7 and puberty, nocturnal melatonin
production is at its lifetime peak, and sleep at this age
is deep and restorative. At this age, if a child is sleepy
during the day, parents should be concerned.
Adolescence
In contrast, adolescents are known for their daytime

drowsiness. Except for infancy, adolescence is the
most rapid period of body growth and development.
Although teenagers need about an hour more sleep
each day than they did as young children, most of
them actually sleep an hour or so less. Parents often
blame teenagers busy schedule of activities for their
grogginess and difficulty awakening in the morning,
and this does play a role. However, the problem is also
partly biological. One study indicated that some adolescents might have delayed sleep phase syndrome,
where they are not sleepy until well after the usual bedtime and cannot wake at the time required for school,
producing conflicts between parents and sleepy teenagers as well as with secondary schools, which usually
start earlier than elementary schools. Other research

indicates that early high school start times contribute
to sleep deprivation among teens, which can lead to
mood swings, behavioral problems, and difficulties
with concentration and learning.
Getting a good nights

sleep during pregnancy
In a National Sleep Foundation poll, nearly
eight in 10 women reported disturbed sleep
during pregnancy. Here are some tips to help you get a
better nights sleep when youre expecting:
Avoid spicy, fried, or acidic foods (such as tomato
Adulthood
During young adulthood, sleep patterns usually seem

stable but in fact are slowly evolving. Between age 20
and age 30, the amount of slow-wave sleep drops by
about half, and nighttime awakenings double. By age
40, slow-wave sleep is markedly reduced.
Womens reproductive cycles can greatly influence
sleep. During the first trimester of pregnancy, many
women are sleepy all the time and may log an extra
two hours a night if their schedules permit. As pregnancy continues, hormonal and anatomical changes
reduce sleep efficiency so that less of a womans time
in bed is actually spent sleeping. As a result, fatigue
increases (see Getting a good nights sleep during
pregnancy, at right). The postpartum period usually
brings dramatic sleepiness and fatiguebecause the
mothers ability to sleep efficiently has not returned to
normal, because she is at the mercy of her newborns
rapidly cycling shifts between sleeping and waking, and because breast-feeding promotes sleepiness.
Researchers are probing whether sleep disturbances
during pregnancy may contribute to postpartum
depression and compromise the general physical and
mental well-being of new mothers.
products), which contribute to heartburn.

If you have heartburn, elevate your pillow or raise the
head of your bed by placing blocks under the bedposts.

Prevent nausea by eating frequent snacks during
the day.
If you feel drowsy, take a midday nap.
Exercise regularly, which will help reduce leg cramps and
improve sleep.
Cut down on fluids before bedtime to reduce nighttime
trips to the bathroom.

Use pillows or special pregnancy cushions to support
your abdomen.
Women who arent pregnant may experience

monthly shifts in sleep habits. During the second
phase of the menstrual cycle, between ovulation and
the next menses, some women fall asleep and enter
REM sleep more quickly than usual. A few experience
extreme sleepiness. Investigators are studying the relationship between such sleep alterations, cyclic changes
in body temperature, and levels of the hormone progesterone to see whether these physiologic patterns
also correlate with premenstrual mood changes.
Table 1 Sleep changes during adulthood

As people age, it takes longer to fall asleep, a phenomenon called increased sleep latency. And sleep efficiencythe percentage of time spent
asleep while in beddecreases as well.
Age 20
Age 40
Age 60
Age 70
Age 80
Time to fall asleep
16 minutes
17 minutes
18 minutes
18.5 minutes
19 minutes
Total sleep time
7.5 hours
7 hours
6.2 hours
6 hours
5.8 hours
Time in stage N2 sleep
47%
51%
53%
55%
57%
Time in stage N3 sleep
20%
15%
10%
9%
7.5%
Time in REM sleep
22%
21%
20%
19%
17%
Time asleep while in bed
95%
88%
84%
82%
79%
Source: Sleep, Nov. 1, 2004, pp. 1255 73.
Improving Sleep
Snoozing news
The average length of time Americans spend sleeping has
dropped from about nine hours a night in 1910 to about
seven hours today.
Middle age
As men and women enter middle age, slow-wave sleep

continues to diminish. Nighttime awakenings become
more frequent and last longer. Waking after about three
hours of sleep is particularly common. During menopause, many women experience hot flashes that can
interrupt sleep and lead to long-term insomnia. Obese
people are more prone to nocturnal breathing problems, which often start during middle age. Men and
women who are physically fit sleep more soundly as
they grow older, compared with their sedentary peers.
The later years
Like younger people, older adults still spend about

20% of sleep time in REM sleep, but other than that,
Improving Sleep
they sleep differently. Slow-wave sleep accounts for

less than 5% of sleep time, and in some people it is
completely absent. Falling asleep takes longer, and the
shallow quality of sleep results in dozens of awakenings during the night. Doctors used to reassure older
people that they needed less sleep than younger ones
to function well, but sleep experts now know that isnt
true. At any age, most adults need seven and a half
to eight hours of sleep to function at their best. Since
older people often have trouble attaining this much
sleep at night, they frequently supplement nighttime
sleep with daytime naps. This can be a successful
strategy for accumulating sufficient total sleep over a
24-hour period. However, if you find that you need a
nap, its best to take one midday nap, rather than several
brief ones scattered throughout the day and evening.
Sleep disturbances in elderly people, particularly
in those who have Alzheimers disease or other forms
of dementia, are very disruptive for caregivers. In one
study, 70% of caregivers cited these problems as the
decisive factor in seeking nursing home placement for
a loved one.
S p e c i a l S e c t ion
Dangers of sleep deprivation
any people dont realize that lack of sufficient sleep can

lead to a range of ill effects, triggering mild to potentially
life-threatening consequences, from weight gain to a
heart attack (see Figure 4). Sleep deprivation is broadly categorized as complete or partial, based on duration and severity.
Complete sleep deprivation

Normally, you go about 16 or 17
hours between sleep sessions.
Complete sleep deprivation happens as the hours extend beyond
this point. First you feel tired, then
exhausted. By 2 or 3 a.m., many
people have a hard time keeping
their eyes open, but the effects
extend throughout the body. Simple tasks that you would normally
have no trouble accomplishing
start to become difficult.
In fact, a number of studies of
hand-eye coordination and reaction time have shown that such
sleep deprivation can be as debilitating as being intoxicated. In one
study, volunteers stayed awake for
28 hours, beginning at 8 a.m., and
periodically took driving simulation tests. At a different time,
the volunteers driving ability was
tested after drinking 10 to 15 grams
of alcohol at 30-minute intervals
www. h e a l t h . h a r v a r d . e d u
until their blood alcohol content

reached 0.10%. The study concluded that 24 hours of wakefulness had the same deleterious effect
on driving ability as that of a blood
alcohol content of 0.10%enough
to be charged with driving while
intoxicated in most states.
Sleep deprivation also leaves
you prone to two potentially dangerous phenomena, microsleeps
and automatic behavior (see page
12), which play a role in thousands
of transportation accidents each
year. When complete sleep deprivation extends for two or three
days, people have difficulty completing tasks demanding a high
attention level and often experience mood swings, depression,
and increased feelings of tension.
Sleep deprivation is so debilitating
that it is sometimes used as a component of military interrogation.
Performance is also highly
influenced by fluctuations in circadian rhythms. For example, sleepdeprived people may still function
fairly well during the morning and
evening. But during the peaks of
sleepiness in the afternoon and
overnight hours, people often literally cannot stay awake and may
fall asleep while standing, sitting,
or even while talking on the telephone, working on the computer,
or eating. A small percentage experience paranoia and hallucinations.
Partial sleep deprivation

Partial sleep deprivation occurs
when you get some sleep, but not
100% of what you need. Experts
refer to this as building up a sleep
debt. An example would be when
a person who needs seven or eight
hours of sleep gets only four to six
hours for several nights in a row.
After a single night of short
sleep, most people function at or
near their normal level. They may
not feel great, but they can usually
get through the day without others noticing that anything is amiss.
After two or more nights of short
sleep, people usually show signs
of irritability and sleepiness. Work
Improving Sleep
Special Section
| Dangers of sleep deprivation
Figure 4 Health consequences of insufficient sleep

Respiratory
More likely to catch a cold
Cardiovascular
Boost in blood pressure
Higher likelihood of a heart attack
Metabolic
Propensity for packing on pounds
Increased risk of developing diabetes
Mental
More prone to
depression and
anxiety
People who skimp on sleep face a higher risk of numerous health problems.
performance begins to sufferparticularly on complicated tasksand

people are more likely to complain
of headaches, stomach problems,
and sore joints. In addition, people
face a far higher risk of falling asleep
on the job and while driving.
Long-term partial sleep deprivation occurs when someone gets
less than the optimal amount
of sleep for months or years on
enda common scenario for
insomniacs and people with sleep
disorders. But even healthy people
who cant resist the round-theclock commerce, communication,
and entertainment opportunities
our 24/7 society now offers may
fall prey to this problem.
In a landmark study of human
sleep deprivation, researchers followed a group of student volunteers
who slept only four hours nightly
for six consecutive days. The volunteers developed higher blood
10
Imp r ov i n g S l e e p
pressure and higher levels of the

stress hormone cortisol, and they
produced only half the usual number of antibodies to a flu vaccine.
The sleep-deprived students also
showed signs of insulin resistance
a condition that is the precursor of
type 2 diabetes. All the changes
which were reversed when the students made up the hours of lost
sleephelp explain why ongoing
sleep debt raises the risk of a number of health problems.
Sleep loss exacts a toll on the
mind as well as the body. In another
study, 48 healthy men and women
who had been averaging seven to
eight hours of sleep nightly were
divided into four groups. One
group slept eight hours, another
slept six, and the third just four
hours per night. The fourth group
went without sleep for three days.
Every two hours during their waking periods, all the participants
completed sleepiness evaluation

questionnaires and took tests of
reaction time, memory, and cognitive ability.
Over the course of two weeks,
reaction times in the group that
slept eight hours a night remained
about the same, and their scores on
the memory and cognitive tasks
rose steadily. In contrast, scores for
the four-hour and six-hour sleepers drew closer to those of the
fourth group, whose scores had
plummeted during their three days
without sleep. After two weeks, the
four-hour sleepers were cognitively
in no better shape than the sleepless group after its first night awake.
Their memory scores and reaction times were about on par with
those of the sleepless after their
second consecutive all-nighter.
The six-hour sleepers performed
adequately on the cognitive test
but lost ground on reaction time
and memory, logging scores that
approximated those of the sleepless
after their first night awake.
Meanwhile, the six-hour and
the four-hour sleepers were failing to gauge reliably how sleepy
they had become. At the end of the
study, their self-rated sleepiness
scores were leveling off, even as
their performance scores continued to decline.
How sleep loss harms

your health
A growing number of studies have
linked long-term sleep deficits
with significant health problems.
Dangers of sleep deprivation | Special Section
Viral infections
Anecdotal evidence supports the
notion that when youre tired and
run-down, youre more likely to
get sick. A 2009 study in Archives
of Internal Medicine offers some
proof. Researchers tracked the
sleep habits of 153 men and women
for two weeks, then quarantined
them for five days and exposed
them to cold viruses. People
Leptin who
Ghrelin
slept an average of less than seven
hours per night
Sleepwere three times
deprevation
as likely to get
sick as those who
averaged at least eight hours.
Weight gain
Not getting enough sleep makes
you more likely to gain weight,
according to a 2008 review article
in the journal Obesity that analyzed
findings from 36 different studies
of sleep duration and body weight.
The link appears to be especially

strong among children. Lack of
sufficient sleep tends to disrupt
hormones that control hunger and
appetite, and the resulting daytime
fatigue often discourages you from
exercising (see Figure 5). Excess
weight, in turn, increases the risk
of a number of health problems
Increased
including
some of those listed in
hunger
the following paragraphs.
Increased
Increased
oportunity to eat
caloric intake
Diabetes
A 2009 report in Diabetes Care
Altered
found a sharp increase in the risk
thermoregulation
Reduced
of type 2 diabetes in people
with
energy
expenditure
Increased
persistent insomnia. People who
fatigue
had insomnia for a year or longer
and who slept less than five hours
per night had a threefold higher
risk of type 2 diabetes compared
with those who had no sleep
complaints and who slept six
or more hours nightly. As with

overweight and obesity (which
are also closely linked to type 2
diabetes), the underlying cause is
thought to involve a disruption
of the bodys normal hormonal
regulation resulting from insufficient sleep.
High blood pressure

Researchers involved in the diabetes study also evaluated risk of high
blood pressure among the same
Obesity
group
of people, which included
more than 1,700 randomly chosen
men and women from rural Pennsylvania. As described in a 2009
article in the journal Sleep, the
researchers found the risk of high
blood pressure was three-and-ahalf times greater among insomniacs who routinely slept less than
six hours per night compared with
Figure 5 How sleep loss may lead to weight gain

Greater hunger
More opportunity
to eat
Altered ability to
control body
temperature
Sleep deprivation
Increased fatigue
Increased caloric
intake
Reduced energy
expenditure
Obesity
Staying up too late at night means youll have more opportunities to eat, but thats not the only problem. Sleep deprivation
can alter your bodys metabolism, making you feel hungrier and slowing your metabolism. Youll also feel more tired during
the day, which means youre less likely to exercise.
Obesity, March 2008.
Improving Sleep
11
Special Section
| Dangers of sleep deprivation
normal sleepers who slept six or

more hours nightly.
Heart disease
A number of studies have linked
short-term sleep deprivation with
several well-known risk factors
for heart disease, including higher
cholesterol levels, higher triglyceride levels, and higher blood pressure. One such report, published
in a 2009 issue of Sleep, included
more than 98,000 Japanese men
and women ages 40 to 79 who
were followed for just over 14
years. Compared with women
who snoozed for seven hours,
women who got no more than
four hours of shut-eye were twice
as likely to die from heart disease,
the researchers found.
One common cause of poor
sleep, sleep apnea (see page 28),
also raises heart disease risk. In
the Wisconsin Sleep Cohort study,

people with severe sleep apnea
were three times more likely to die
of heart disease during 18 years
of follow-up than those without
apnea. When researchers excluded
those who used a breathing
machine (a common apnea treatment), the risk jumped to more
than five times higher. Apnea spells
can trigger arrhythmias (irregular heartbeats), and the condition
also increases the risk of stroke and
heart failure.
Mental illness
A study of about 1,000 adults
ages 21 to 30 found that, compared with normal sleepers, those
who reported a history of insomnia during an interview were four
times as likely to develop major
depression by the time of a second
interview three years later. And
Microsleeps and automatic behavior

Microsleeps are brief episodes of sleep that occur in the midst of ongoing
wakeful activity. They can occur in people who are sleep deprived. These are
the head nods some people experience when trying to stay awake during a
lecture, for example. They usually last just a few seconds but can go on for
10 or 15 secondsand pose a grave danger if they happen when a person
is driving. Brain wave monitoring by EEG of someone experiencing micro
sleeps shows brief periods of stage N1 sleep intruding into wakefulness.
During this time, the brain does not respond to noise or other sensory inputs,
and you dont react to things happening around you.
Automatic behavior refers to a period of several minutes or more during
which a person is awake and performing routine duties but not attending
to his or her surroundings or responding to changes in the environment.
Examples include a driver who keeps the car on the road but misses an
intended exit and a train engineer who can continue pressing a lever at
regular intervals but doesnt notice an obstruction on the track.
12
Imp r ov i n g S l e e p
two studies in young peopleone

involving 300 pairs of young twins,
and another including about 1,000
teenagersfound that sleep problems developed before a diagnosis
of major depression and (to a lesser
extent) anxiety. Sleep problems in
the teenagers preceded depression
69% of the time and anxiety disorders 27% of the time.
Mortality
In the Japanese heart disease study
described above, short sleepers of
both genders had a 1.3-fold increase
in mortality compared with those
who got sufficient sleep. Severe
sleep apnea raises the risk of dying
early by 46%, according to a 2009
study of 6,400 men and women
whom researchers followed for an
average of eight years. Although
only about 8% of the men in the
study had severe apnea, those who
did and who were between 40 and
70 years of age were twice as likely
to die from any cause as healthy
men in the same age group.
Healthy sleep habits
Clearly, getting enough sleep is
just as important as other vital elements of good health, such as eating a healthy diet, getting regular
exercise, and practicing good dental hygiene. In short, sleep is not a
luxury but a basic component of a
healthy lifestyle.
Just like purchasing healthy
foods, taking an after-dinner
walk, or flossing your teeth, getting adequate sleep requires time
Dangers of sleep deprivation | Special Section
and discipline. Mentally block off

certain hours for sleep and then
follow through on your intention,
avoid building up a sleep debt, and
take steps to set up an ideal sleep
environment. Seek a doctors help
if conventional steps toward good
sleep dont work.
This doesnt mean that you
cant have any fun, or that you
need to beat yourself up if you
dont get eight hours of sleep
365 days a year. Just as an occasional ice cream sundae wont

make you obese, staying up a few
extra hours for a party or to meet
a deadline is perfectly acceptableas long as you make plans
to compensate the next day by
sleeping in, taking a short afternoon nap, or going to bed earlier.
If you have to get up at 7 a.m. to
be at work by 9, youd best forgo
late-night talk showsor record
them to watch the next evening.

If you dont get to bed until 2
a.m. one night, allow time over
the next day or two to catch up
on lost sleep. But over the long
haul, you need to make sure you
consistently get enough sleep.
Sleep decisions are a qualityof-life issue. Whatever your interests and goals, getting enough
sleep puts you in a better position
to enjoy and achieve them.
Improving Sleep
13
General ways to improve sleep

any things can interfere with sleep, ranging from
anxiety to an unusual work schedule. People who
have difficulty sleeping often discover that their daily
routine holds the key to nighttime woes.
cause headache, irritability, and extreme fatigue, some

people find it easier to cut back gradually than to go
cold turkey. Those who cant or dont want to give up
caffeine should avoid it after 2 p.m., or noon if they are
especially caffeine-sensitive.
First-line strategies
Stop smoking or chewing tobacco

Nicotine is a central nervous system stimulant that
can cause insomnia. This potent drug makes it harder
to fall asleep because it speeds your heart rate, raises
blood pressure, and stimulates fast brain wave activity that indicates wakefulness. In people addicted to
nicotine, a few hours without it is enough to induce
withdrawal symptoms; the craving can even wake a
smoker at night. People who kick the habit fall asleep
more quickly and wake less often during the night.
Sleep disturbance and daytime fatigue may occur
during the initial withdrawal from nicotine, but
even during this period, many former users report
improvements in sleep. If you continue to use tobacco,
avoid smoking or chewing it for at least one to two
hours before bedtime.
Before examining specific sleep problems, it makes

sense to address some common enemies of sleep and
tips for dealing with them.
Cut down on caffeine

Caffeine drinkers may find it difficult to fall asleep. Once
they drift off, their sleep is shorter and lighter. For some
people, a single cup of coffee in the morning means a
sleepless night. That may be because caffeine blocks the
effects of adenosine, a neurotransmitter thought to promote sleep. Caffeine can also interrupt sleep by increasing the need to urinate during the night.
People who suffer from insomnia should avoid caffeine as much as possible, since its effects can endure
for many hours. Because caffeine withdrawal can
Tips for a better nights sleep

Hygiene is the application of scientific knowledge to maintain good health. These procedures are known as
sleep hygiene, because they represent scientific thinking about maintaining healthy sleep patterns.
Go to bed and wake up at the same time every day, even on
weekends.
Use the bed only for sleeping or sex.
Forgo naps, especially close to bedtime.
Limit the time you spend in bed. Turn in only when youre
sleepy. If you dont fall asleep within 15 minutes or if you

wake up and cant fall back to sleep within that amount of
time, get out of bed and do something relaxing until you
feel sleepy again.
Avoid caffeine-containing beverages (coffee, many teas,
chocolate, and cola drinks) after 2 p.m., or noon if youre

caffeine-sensitive.
14
Improving Sleep
Avoid eating foods that contribute to heartburn.

Dont drink alcohol for at least two hours before bedtime.
Limit fluids before bedtime to minimize nighttime trips to
the bathroom.
Stop smoking, or at least do not smoke for one to two hours
before turning in for the night.

Exercise regularly (but not within two hours of bedtime).
Keep the bedroom cool, dark, and as quiet as possible.
Replace a worn-out or uncomfortable mattress.
Take a hot bath before bedtime.
Use relaxation techniques before bedtime.
Use alcohol cautiously

Alcohol depresses the nervous system, so a nightcap
can help some people fall asleep. However, the quality of this sleep is abnormal. Alcohol suppresses REM
sleep, and the soporific effects disappear after a few
hours. Drinkers have frequent awakenings and sometimes frightening dreams. Alcohol may be responsible for up to 10% of chronic insomnia cases. Also,
because alcohol relaxes throat muscles and interferes
with brain control mechanisms, it can worsen snoring
and other nocturnal breathing problems, sometimes
to a dangerous extent.
Drinking during one of the bodys intrinsic sleepy
timesmidafternoon or at nightwill induce more
sleepiness than imbibing at other times of day. Even
one drink can make a sleep-deprived person drowsy.
In an automobile, the combination significantly
increases a persons chance of having an accident.
Be physically active
Regular aerobic exercise like walking, running, or
swimming provides three important sleep benefits:
you fall asleep faster, attain a higher percentage of deep
sleep, and awaken less often during the night. Exercise
seems to be of particular benefit to older people. In
one study, physically fit older men fell asleep in less
than half the time it took for sedentary men, and they
woke up less often during the night.
Exercise is the only known way for healthy adults to
boost the amount of deep sleep they get. Research shows
that older men and women who report sleeping normally can still increase the amount of time they spend in
deep sleep if they do some form of aerobic activity.
But try to avoid exercise within two hours of bedtime because exercise is stimulating and can make it
harder to fall asleep.
Improve your sleep surroundings
People respond to cues in their environment. Removing the television, telephone, and office equipment
from the bedroom reinforces that this room is meant
for sleeping. An ideal environment is quiet, dark, and
relatively cool, with a comfortable bed and minimal
clutter. Banish reminders or discussions of stressful
issues to another room.
Stick to a regular schedule

A regular sleep schedule keeps the circadian sleep/
wake cycle synchronized (see Your internal clock,
page 4). People with the most regular sleep habits
report the fewest problems with insomnia and the
least depression. Experts advise getting up at about
the same time every day, even after a late-night party
or fitful sleep. Napping during the day can also make
it harder to get to sleep at night.
Keep a sleep diary. Keeping a sleep diary may help
you uncover some clues about whats disturbing your
sleep. If possible, you should do this for a month, but
even a weeks worth of entries can be useful.
Use strategic naps. If your goal is to sleep longer at night, napping is a bad idea. Because your daily
sleep requirement remains constant, naps take away
from evening sleep.
But if your goal is to improve your alertness during the day, a scheduled nap may be just the thing. If
an insomniac is anxious about getting enough sleep,
then a scheduled nap may improve the quality of
nighttime sleep by reducing anxiety.
If possible, nap shortly after lunch. People who
snooze later in the afternoon tend to fall into a deeper
sleep, which causes greater disruption at night. An
ideal nap lasts no longer than an hour, and even a
15- to 20-minute nap has significant alertness benefits. Shorten or eliminate naps that produce lingering
grogginess.
Ways to control bedroom noise

A quiet bedroom can help contribute to a good nights
sleep, particularly among older adults, who spend
less time in deep sleep and, therefore, are more easily
awakened by noises. Here are some ways to reduce or
disguise noises that can interfere with sleep:
Use earplugs.
Decorate with heavy curtains and rugs, which absorb
sounds.
Install double-paned windows.
Use a fan or other appliance that produces a steady
white noise. White noise devices, designed specifically

to provide this kind of steady hum, are available in
stores, as are CDs that provide soothing sounds.
Improving Sleep
15
Medical conditions and sleep problems
eople who feel they sleep perfectly well may still be

troubled by excessive daytime sleepiness because
of a variety of underlying medical illnesses. A sleep
disturbance may be a symptom of a health issue or
an adverse effect of therapy to treat the problem. The
stress of chronic illness can also cause insomnia and
daytime drowsiness.
Illnesses that affect sleep
Common conditions often associated with sleep problems include heartburn, diabetes, cardiovascular disease, musculoskeletal disorders, kidney disease, mental
illness, neurological disorders, respiratory problems,
and thyroid disease. In addition, a number of prescription and over-the-counter medications used to
treat these and other health problems can impair sleep
quality and quantity (see Table 2).
Heartburn
Lying down in bed often worsens heartburn, which is
caused by the backup of stomach acid into the esophagus. You may be able to avoid this problem by abstaining from heavy or fatty foodsas well as coffee and
alcoholin the evening. You can also use gravity to
your advantage by elevating your upper body with an
under-mattress wedge or blocks placed under the bedposts. Over-the-counter and prescription drugs that
suppress stomach acid secretion can also help.
Diabetes
Night sweats, a frequent need to urinate, or symptoms
of hypoglycemia (low blood sugar) often rouse people
with diabetes whose blood sugar levels are not well
controlled. If diabetes has damaged nerves in the legs,
nighttime movements or pain may also disturb sleep.
Heart disease
Patients with heart failure may awaken during the
16
Improving Sleep
night feeling short of breath because extra body fluid

accumulates around their lungs when theyre lying
down. Using pillows to elevate the upper body may
help. These people can also be awakened just as they
are falling asleep by a characteristic breathing pattern
called Cheyne-Stokes respiration, a series of increasingly deep breaths followed by a brief cessation of
breathing. Benzodiazepine sleep medications (see
Prescription medications for insomnia, page 22)
help some people to stay asleep despite this breathing
disturbance, but others may need to use supplementary oxygen or a device that increases pressure in the
upper airway and chest cavity to help them breathe
and sleep more normally (see Positive airway pressure, page 29).
Men with heart failure frequently have obstructive sleep apnea, which can disrupt sleep, cause daytime sleepiness, and worsen heart failure. In people
with coronary artery disease, the natural fluctuations
in circadian rhythms may trigger angina (chest pain),
arrhythmia (irregular heartbeat), or even heart attack
while asleep.
Musculoskeletal disorders
Arthritis pain can make it hard for people to fall asleep
and to resettle when they shift positions. In addition, treatment with corticosteroids frequently causes
insomnia. You may find it helpful to take aspirin or
a nonsteroidal anti-inflammatory drug (NSAID) just
before bedtime to relieve pain and swelling in your
joints during the night.
People with fibromyalgiaa condition characterized by painful ligaments and tendonsare likely
to wake in the morning still feeling fatigued and as
stiff and achy as a person with arthritis. Researchers
who analyzed the sleep of fibromyalgia sufferers have
found that at least half have abnormal deep sleep, in
which slow brain waves are mixed with waves usually
associated with relaxed wakefulness, a pattern called
alpha-delta sleep. In one study, 62 people with fibromyalgia received treatment for six weeks with either
the NSAID naproxen, the tricyclic antidepressant
amitriptyline, both drugs, or a placebo. Almost half
of those who took low doses of amitriptyline reported
sleeping and feeling better.
Kidney disease
Kidney disease can cause waste products to build up
in the blood and can result in insomnia or symptoms
of restless legs syndrome (see page 33). Although
researchers arent sure why, kidney dialysis or transplant does not always return sleep to normal.
Mental illness
Almost all people with anxiety or depression have trouble falling asleep and staying asleep. In turn, not being
able to sleep may become a focus of some sufferers
ongoing fear and tension, causing further sleep loss.
General anxiety. Severe anxiety, formally known
as generalized anxiety disorder, is a mental illness
characterized by persistent, nagging feelings of worry,
apprehension, or uneasiness. These feelings are either
unusually intense or out of proportion to the real
troubles and dangers of the persons everyday life. People with the disorder typically experience excessive,
persistent worry every day or almost every day for a
period of six months or more. Common symptoms
include trouble falling asleep, trouble staying asleep,
and not feeling rested after sleep.
Phobias and panic attacks. Phobias, which are
intense fears related to a specific object or situation,
rarely cause sleep problems unless the phobia is itself
sleep-related (such as fear of nightmares or of the bedroom). Panic attacks, on the other hand, often strike at
night. In fact, the timing of nocturnal attacks helped
convince psychiatrists that these episodes are biologically based. Sleep-related panic attacks do not occur
during dreaming, but rather in stage N2 and stage N3
sleep, which are free of psychological triggers. In many
phobias and panic disorders, recognizing and treating
the underlying problemoften with an anti-anxiety
medicationmay solve the sleep disturbance.
Depression. Because almost 90% of people with
serious depression experience insomnia, a physiwww.h e a l t h . h a r v a r d . e d u
Coping with frequent nighttime urination

Nocturiathe need to get up frequently to urinate during the nightis a common cause of sleep loss, especially
among older adults. It affects nearly two-thirds of adults
ages 55 to 84 at least a few nights per week.
A mild case causes a person to wake up at least twice
during the night; in severe cases, a person may get up as
many as five or six times. Not surprisingly, this can lead to
significant sleep deprivation and daytime fatigue.
Nocturia becomes more common with age. As we get
older, our bodies produce less of an antidiuretic hormone
that enables us to retain fluid. With lower concentrations
of this hormone, we produce more urine at night. Also, the
bladder tends to lose holding capacity as we age, and older
people are more likely to suffer from medical problems that
affect the bladder.
Nocturia has numerous possible other causes, including
some of the disorders mentioned in this report (heart failure,
diabetes), other medical conditions (urinary tract infection,
an enlarged prostate, liver failure, multiple sclerosis, sleep
apnea), and medication (especially diuretics). Some cases
are caused or exacerbated by excessive fluid intake after
dinner, especially drinks containing alcohol or caffeine.
Therapies for nocturia fall into three categories: treatments to correct medical causes, behavioral interventions, and medication. The first step is to try to identify the
cause and correct it. If this is unsuccessful, try behavioral
approaches such as cutting down on how much you drink in
the two hours before bedtime, especially caffeine and alcohol. If the nocturia persists, your doctor may prescribe one
of a growing number of medications approved to treat an
overactive bladder. The most commonly used is desmopressin (DDAVP, Stimate), which mimics some of the action of the
antidiuretic hormone. If the problem stems from increased
contractions of the bladder, relaxant agents such as tol
terodine (Detrol) and oxybutynin (Ditropan) can be effective.
cian evaluating a person with insomnia will consider

depression as a possible cause. Waking up too early
in the morning is a hallmark of depression, and some
depressed people have difficulty falling asleep or get
fitful sleep throughout the whole night. In chronic,
low-grade depression, insomnia or sleepiness may
be the most prominent symptom. Laboratory studies have shown that people who are depressed spend
less time in slow-wave sleep and may enter REM sleep
more quickly at the beginning of the night.
Bipolar disorder. Disturbed sleep is a prominent
feature of bipolar disorder (manic-depressive illness).
Sleep loss may exacerbate or induce manic symptoms
Improving Sleep
17
or temporarily alleviate depression. During a manic

episode, a person may not sleep at all for several days.
Such occurrences are often followed by a crash during which the person spends most of the next few
days in bed.
Schizophrenia. Some people with schizophre-
nia sleep very little when they enter an acute phase

of their illness. Between episodes, their sleep patterns
are likely to improve, although many schizophrenics
rarely obtain a normal amount of deep sleep.
Table 2 Medications that may affect sleep

A number of drugs steal sleep, while others may cause unwanted drowsiness. Your doctor may be able to suggest alternatives that do not
disrupt sleep.
Possible effect on sleep and
daytime functioning
Medication
Used to treat
Common examples
Anti-arrhythmics
Heart rhythm problems
procainamide (Procanbid),
quinidine (Cardioquin),
disopyramide (Norpace)
Nighttime sleep difficulties,

daytime fatigue
Beta blockers
High blood pressure, heart rhythm

problems, angina
atenolol (Tenormin), metoprolol

(Lopressor), propranolol (Inderal)
Insomnia, nighttime awakenings,

nightmares
Clonidine
High blood pressure; sometimes

prescribed off-label for alcohol
withdrawal, smoking cessation, or
other health problems
clonidine (Catapres)
Daytime drowsiness and fatigue,

disrupted REM sleep; less
commonly, restlessness, early
morning awakening, nightmares
Corticosteroids
Inflammation, asthma
prednisone (Sterapred, others)
Daytime jitters, insomnia
Diuretics
High blood pressure
chlorothiazide (Diuril),
chlorthalidone (Hygroton),
hydrochlorothiazide (Esidrix,
HydroDIURIL, others)
Increased nighttime urination,

painful calf cramps during sleep
Medications
containing alcohol
Cough, cold, and flu
Coricidin HBP, Nyquil Cough,

Theraflu Warming Relief
Suppressed REM sleep, disrupted

nighttime sleep
Medications containing
caffeine
Decreased alertness
NoDoz, Vivarin, Caffedrine
Wakefulness that may last up to

six to seven hours
Headaches and other pain
Anacin, Excedrin, Midol
Nicotine replacement
products
Smoking
nicotine patches (Nicoderm), gum

(Nicorette), nasal spray or inhalers
(Nicotrol), and lozenges (Commit)
Insomnia, disturbing dreams
Sedating antihistamines*
Cold and allergy symptoms
diphenhydramine (Benadryl),
chlorpheniramine (Chlor-Trimeton)
Drowsiness
Motion sickness
dimenhydrinate (Dramamine)
Depression, anxiety
fluoxetine (Prozac), sertraline

(Zoloft), paroxetine (Paxil)
Decreased REM sleep, daytime

fatigue
Sympathomimetic stimulants Attention deficit disorder
dextroamphetamine (Dexedrine),
methamphetamine (Desoxyn),
methylphenidate (Ritalin)
Difficulty falling asleep, decreased

REM and non-REM deep sleep
Theophylline
Asthma
theophylline (Slo-bid, Theo-Dur,

others)
Wakefullness similar to that

caused by caffeine
Thyroid hormone
Hypothyroidism
levothyroxine (Levoxyl, Synthroid,

others)
Sleeping difficulties (at higher

doses)
Selective serotonin reuptake

inhibitors (SSRIs)
*These medications are also found in over-the-counter sleep aids (see page 25).
18
Improving Sleep
Other neurological disorders

Certain brain and nerve disorders can contribute to
sleeplessness.
Dementia. Alzheimers disease and other forms
of dementia may disrupt sleep regulation and other
brain functions. Wandering, disorientation, and agitation during the evening and night, a phenomenon
known as sundowning, can require constant supervision and place great stress on caregivers. In such
cases, small doses of antipsychotic medications such
as haloperidol (Haldol) and thioridazine (Mellaril) are
more helpful than benzodiazepine drugs.
Epilepsy. People with epilepsy are twice as likely
as others to suffer from insomnia. Brain wave disturbances that cause seizures can also cause deficits in
slow-wave sleep or REM sleep. Antiseizure drugs can
cause similar changes at first, but tend to correct these
sleep disturbances when used for a long time. About
one in four people with epilepsy has seizures that
occur mainly at night, causing disturbed sleep and
daytime sleepiness. Sleep deprivation can also trigger
a seizure, a phenomenon noted in college infirmaries
during exam periods, as some students suffer their
first seizures after staying up late to study.
Headaches, strokes, and tumors. People who are
prone to headaches should try to avoid sleep deprivation, as lack of sleep can promote headaches. Both
cluster headaches and migraines may be related to
changes in the size of blood vessels leading to the cortex of the brain; pain occurs when the walls of the
blood vessels dilate. Researchers theorize that as the
body catches up on missed sleep, it spends more time
in delta sleep, when vessels are most constricted, making the transition to REM sleep more dramatic and
likely to induce a headache. Headaches that awaken
people are often migraines, but some migraines can be
relieved by sleep.
Sleepiness coupled with dizziness, weakness, headache, or vision problems may signal a serious problem
such as a brain tumor or stroke, which requires immediate medical attention.
Parkinsons disease. Almost all people with Parkinsons disease have insomnia. Just getting in and out
of bed can be a struggle, and the disease often dis-
rupts sleep. Some arousals are from the tremors and

movements caused by the disorder, and others seem
to result from the disorder itself. As a result, daytime
sleepiness is common. Treatment with sleeping pills
may be difficult because some drugs can worsen Parkinsons symptoms. Some patients who take drugs
such as levodopa, the mainstay of Parkinsons treatment, develop severe nightmares; others experience
disruption of REM sleep. However, the use of these
medications at night is important to maintain the
mobility needed to change positions in bed. A bed rail
or an overhead bar (known as a trapeze) may make it
easier for people with Parkinsons to move about and,
therefore, lead to better sleep.
Respiratory problems
Circadian-related changes in the tone of the muscles surrounding the airways can cause the airways
to constrict during the night, raising the potential
for nocturnal asthma attacks that rouse the sleeper
abruptly. Breathing difficulties or fear of having an
attack may make it more difficult to fall asleep, as can
the use of steroids, theophylline, or other breathing
medications that also have a stimulating effect, similar to that of caffeine. One study found that nearly
75% of people with asthma experienced frequent
awakenings every week. People who have emphysema or bronchitis may also have difficulty falling
and staying asleep because of excess sputum production, shortness of breath, and coughing.
Thyroid disease
An overactive thyroid gland (hyperthyroidism) can
cause sleep problems. The disorder overstimulates
the nervous system, making it hard to fall asleep,
and it may cause night sweats, leading to nighttime
arousals. Feeling cold and sleepy is a hallmark of an
underactive thyroid (hypothyroidism). Because thyroid function affects every organ and system in the
body, the symptoms can be wide-ranging and sometimes difficult to decipher. Checking thyroid function requires only a simple blood test, so if you notice
a variety of unexplained symptoms, ask your doctor
for a thyroid test.
Improving Sleep
19
Insomnia
eople with insomniathe inability to sleepmay

be plagued by trouble falling asleep, unwelcome
awakenings during the night, and fitful sleep. They
may experience daytime drowsiness, yet still be unable
to nap, and are often anxious and irritable or forgetful
and unable to concentrate.
Although its the most common sleep disturbance,
insomnia is not a single disorder, but rather a general
symptom like fever or pain. Finding a remedy requires
uncovering the cause. Nearly half of insomnia cases
stem from psychological or emotional problems.
Stressful events, mild depression, or an anxiety disorder can keep people awake at night. With proper treatment of the underlying cause, the insomnia usually
recedes. If it doesnt, additional treatment focusing on
sleep may help.
Types of insomnia
One way doctors classify insomnia is by its duration.

Insomnia is considered transient if it lasts only a few
days, short-term if it continues for a few weeks, and
chronic if the problem persists.
The causes of transient or short-term insomnia
are usually apparent to the suffererthe death of or
separation from a loved one, nervousness about an
upcoming event (such as a wedding, public speaking
engagement, or move), jet lag, or discomfort from an
illness or injury. Chronic insomnia may be caused by
a number of medications or medical conditions (see
Snoozing news
The National Center on Sleep Disorders Research estimates that each year, sleep disorders, sleep deprivation,
and sleepiness add $15.9 billion to the national health
care bill. Additional costs to society for related health
problems, such as lost worker productivity and accidents,
are not included in this calculation.
20
Improving Sleep
Medical conditions and sleep problems, page 16). In

these instances, treating the condition or changing the
medication may relieve the insomnia.
One common form of persistent sleeplessness is
conditioned (learned) insomnia. After experiencing a
few sleepless nights, some people learn to associate the
bedroom with being awake. Taking steps to cope with
sleep deprivationnapping, drinking coffee, having a
nightcap, or forgoing exerciseonly fuels the problem.
As insomnia worsens, anxiety regarding the insomnia
may also worsen, leading to a vicious cycle in which
fears about sleeplessness and its consequences become
the primary cause of the insomnia.
First-line treatment: Behavioral

changes
For chronic insomnia, the treatment of choice is to

change your lifestyle and habits. A careful evaluation
can pinpoint habits that keep you up at night. A sleep
specialist trained in behavioral medicine can help
people with learned insomnia replace their bad habits
with positive ones.
Sleep restriction
People with insomnia often tend to spend more time
in bed, hoping this will lead to sleep. In reality, spending less time in beda technique known as sleep
restrictionpromotes more restful sleep and helps
make the bedroom a welcome sight instead of a torture chamber. As you learn to fall asleep quickly and
sleep soundly, the time in bed is slowly extended until
you obtain a full nights sleep.
Some sleep experts suggest starting with six hours
at first, or whatever amount of time you typically sleep
at night. Setting a rigid early morning waking time
often works best. If the alarm is set for 7 a.m., a sixhour restriction means that no matter how sleepy you
are, you must stay awake until 1 a.m. Once you are
sleeping well during the allotted six hours, you can

add another 15 or 30 minutes, then repeat the process
until youre getting a healthy amount of sleep.
Reconditioning
Developed in the 1970s, this technique reconditions
people with insomnia to associate the bedroom with
sleep. These are the rules:
Use the bed only for sleeping or sex.
Go to bed only when youre sleepy. If youre unable
to sleep, move to another room and do something
relaxing. Stay up until you are sleepy, then return to
bed. If sleep does not follow quickly, repeat.
During the reconditioning process, get up at the
same time every day and do not nap.
The idea is to train your body to associate your bed
with sleep instead of sleeplessness and frustration.
Relaxation techniques
For some people with insomnia, a racing or worried
mind is the enemy of sleep. In others, physical tension
is to blame. Techniques to quiet a racing mindsuch
as meditation, breathing exercises, progressive muscle
relaxation, and biofeedbackcan be learned in behavior therapy sessions or from books, CDs, or classes.
Progressive muscle relaxation, which involves progressively tensing and relaxing your muscles starting
with your feet and working your way up your body,
is a tried-and-true, drug-free technique for achieving both physical and mental relaxation. A typical
approach is this:
Lie on your back in a comfortable position. Put a pillow under your head if you like, or place one under
your knees to relax your back. Rest your arms, with
palms up, slightly apart from your body. Feel your
shoulders relax.
Take several slow, deep breaths through your nose.
Exhale with a long sigh to release tension.
Focus on your feet and ankles. Are they painful or
tense? Tighten the muscles briefly to feel the sensation. Let your feet sink into the floor or the bed. Feel
them getting heavy and becoming totally relaxed. Let
them drop from your consciousness.
Slowly move your attention through different parts of

your body: your calves, thighs, lower back, hips, and
pelvic area; your middle back, abdomen, upper back,
shoulders, arms, and hands; your neck, jaw, tongue,
forehead, and scalp. Feel your body relax and your
lungs gently expand and contract. Relax any spots
that are still tense. Breathe softly.
If thoughts distract you, gently ignore them and
return your attention to your breathing. Your worries and thoughts will be there when you are ready to
acknowledge them.
Another way to release physical tension and relax
more effectively is to use biofeedback. This approach
involves using equipment that monitors involuntary
body states (such as muscle tension or hand temperature) and makes you aware of them. Immediate feedback helps you see how various thoughts or relaxation
maneuvers affect tension, enabling you to learn how
to gain voluntary control over the process. Biofeedback is usually done under professional supervision.
Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) teaches people
new ways of thinking about and then doing things.
CBT has proved helpful in treating addictions, phobias, and anxietyas well as insomnia.
CBT for insomnia aims to change the negative
thoughts and beliefs about sleep into positive ones.
People with insomnia tend to become preoccupied
with sleep and apprehensive about the consequences
of poor sleep. This worry makes relaxing and falling asleep nearly impossible. The basic tenets of this
therapy include setting realistic goals and learning to
let go of inaccurate thoughts that can interfere with
sleep. Common types and examples of these thoughts
include
misattributions (When I feel nervous during the
day, its always because I did not sleep well the night
before)
hopelessness (Ill never get a decent nights rest)
unrealistic expectations (I need eight hours of sleep
tonight or I have to fall asleep before my spouse
does)
Improving Sleep
21
exaggerating consequences (If I dont get to sleep

soon, Ill embarrass myself at tomorrows meeting)
performance anxiety (It will take me at least an hour
to fall asleep).
A cognitive behavioral therapist helps you replace
these maladaptive thoughts with accurate and constructive ones, such as All my problems do not stem
from insomnia, I stand a good chance of getting
a good nights sleep tonight, or My job does not
depend on how much sleep I get tonight. The therapist also provides structure and support while you
practice new thoughts and habits.
In one study, just five sessions of CBT focusing on
proper sleep techniques cut the average time it took
people to fall asleep from 68 minutes to 34 minutes.
Subsequent research on people who did CBT alone
or in combination with the drug zolpidem (see Prescription medications for insomnia, at right) for six
weeks found that both groups improved, but those
who received the combined therapy had a larger
increase in total sleep time. During the subsequent
six months, the participants received no treatment,
CBT alone, or the combined therapy. Those who
received the six-week combined therapy followed by
CBT alone for six months fared the best. The findings, described in a 2009 report in The Journal of the
American Medical Association, suggest that shortterm medical therapy can help initially, but isnt necessary for extended periods of time if you can learn
and stick with good sleep habits.
The biggest obstacle to successful treatment with
CBT is patient commitmentsome people fail to complete all the required sessions or to practice the techniques on their own. Internet-based programs might
help address that problem. Several small studies suggest that online CBT programs that teach people good
sleep hygiene, relaxation techniques, and other strategies can help insomniacs sleep better. One program,
called SHUTi (Sleep Healthy Using the Internet),
helped long-term insomniacs boost their sleep efficiency compared with a control group. Another study
documented at least mild improvements in about 80%
of people who completed five weeks of online CBT, with
35% reporting that their sleep was much improved or
22
Improving Sleep
very much improved. (For more information about

these programs, see Resources, page 48.)
Prescription medications for

insomnia
Prescription medications can be useful for some people with insomnia, usually for transient or short-term
insomnia. But these drugs should be used at the lowest dose and for the shortest possible period of time.
Since behavioral therapies are as effective and may
have longer-lasting beneficial effects, they should be
tried first when possible.
Doctors prescribe several different types of medications to treat insomnia (see Table 3), including
older medications called benzodiazepines, which are
also used to treat anxiety; newer, related medications
known as nonbenzodiazepines, which selectively target
sleep receptors in the brain; and antidepressants, which
are typically prescribed in doses lower than those used
to treat depression. The newest sleep drug, ramelteon,
is classified as a melatonin-receptor agonist.
Benzodiazepines. These medications enhance the
activity of GABA, a neurotransmitter that calms brain
activity. Different benzodiazepines vary in how quickly
they take effect and how long they remain active in
the body. Taken at night, benzodiazepines can lead
to next-day drowsiness and sedation. If your main
problem is getting to sleep, your doctor may prescribe
one that begins working quickly and is short-acting,
such as triazolam (Halcion). If your problem is staying asleep, a drug that lasts longersuch as estazolam
(ProSom) or temazepam (Restoril)may be necessary. These drugs are useful for patients with anxiety
and insomnia that results from it.
One drawback of benzodiazepines is that they
reduce how much deep sleep you get. Also, many people who use benzodiazepines develop tolerancethe
need for more and more of the drug to obtain the same
effect. After a few weeks, the drugs may no longer promote sleep. Another risk is that stopping the medication abruptly after long-term use can cause insomnia
thats even worse than the insomnia you had before
you started taking the drug (a phenomenon known as
rebound). These medications should be discontinued
under a doctors supervision because withdrawal may

lead to muscle tension, restlessness, irritability, or, in
rare cases, convulsions.
Nonbenzodiazepines. These medications also
enhance the sleep-inducing activity of GABA, but
they have a slightly different chemical composition.
While benzodiazepines affect multiple brain recep-
tors, the nonbenzodiazepines act only on the sleep

receptors in your brain, which means they cause fewer
side effects. They also appear to have little or no effect
on deep sleep. Many physicians now prescribe these
drugswhich include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien)in situations
where they formerly prescribed benzodiazepines.
Table 3 Prescription medications for insomnia

Generic name (brand name)
Side effects
Comments
Benzodiazepines (for short-term treatment of insomnia)

alprazolam* (Xanax)
clonazepam* (Klonopin)
diazepam* (Valium)
estazolam (ProSom)
flurazepam (Dalmane)
lorazepam* (Ativan)
quazepam (Doral)
temazepam (Restoril)
triazolam (Halcion)
Clumsiness or unsteadiness, dizziness,

lightheadedness, daytime drowsiness, headache
Should be used with caution by people with sleep

apnea or other breathing difficulties; not to be
used with alcohol or other depressants; tolerance
may develop; withdrawal symptoms occur if
stopped abruptly. Triazolam is a short-acting
medication.
Nonbenzodiazepines (for insomnia)

eszopiclone (Lunesta)
zaleplon (Sonata)
zolpidem (Ambien, Ambien CR)
Headache, daytime drowsiness, dizziness, nausea,

drugged feeling
Avoid combining these medications with alcohol

and certain depressants (including antihistamines,
muscle relaxants, and sedatives).
Antidepressants* (for insomnia, nonrestorative sleep, and depression)

Serotonin modulator
Dizziness, dry mouth, headache, nausea,

constipation or diarrhea, painful erections
Selective serotonin reuptake

inhibitors (SSRIs)
Dry mouth, drowsiness, dizziness, sexual

dysfunction, nausea, diarrhea, headache,
jitteriness, sweating, insomnia, weight gain
Serotonin and norepinephrine

reuptake inhibitor (SNRI)
Upset stomach, excitement or anxiety, dry mouth,

skin sensitivity to sunlight, weight gain, headache
Tetracyclic
Dry mouth, constipation, weight gain, headache,

dizziness
Tricyclics
Dry mouth, dizziness, constipation, incomplete

urination, weight gain, sun sensitivity, sweating,
faintness upon standing, increased heart rate,
sexual dysfunction
trazodone (Desyrel)
citalopram (Celexa)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline (Zoloft)
Certain antidepressants should not be used with

a monoamine oxidase inhibitor (MAOI) or during
immediate recovery from a heart attack.
venlafaxine (Effexor)
mirtazapine (Remeron)
amitriptyline (Elavil)
doxepin (Sinequan)
nortriptyline (Aventyl, Pamelor)
trimipramine (Surmontil)
Melatonin receptor agonist (for insomnia at bedtime)

ramelteon (Rozerem)
Dizziness
May exacerbate depression; not to be used by

people who have severe liver damage or who take
fluvoxamine (Luvox).
*Although the FDA has not approved these drugs for this use, physicians have found that they often help people with insomnia and therefore prescribe them.
Improving Sleep
23
All three drugs make you fall asleep quicker, but

only eszopiclone and zolpidem lengthen total sleep
time. Zaleplon and zolpidem act quickly (within 20
minutes) and, for the most part, wear off before your
typical waking time. Zaleplon wears off especially
quickly, so it may not keep you asleep the whole night
if you take it before bed, but you can take one if you
wake up in the middle of the night and cant fall back
asleep. Eszopiclone takes a little longer to take effect
and also lasts longer. A long-acting version of zolpidem, called Ambien CR, helps with problems with
staying asleep as well as falling asleep.
While zolpidem and zaleplon are both approved
only to treat short-term insomnia (for up to 30 days),
eszopiclone is approved to treat insomnia for up to six
months. This does not mean eszopiclone is necessarily
superiorjust that its manufacturer took the time and
expense to conduct studies to show the drug is safe
and effective for longer use.
While nonbenzodiazepines have fewer drawbacks
than benzodiazepines, theyre not perfect for everyone.
Some people find the drugs arent powerful enough to
put them to sleep. And the drugs may still cause morning grogginess, tolerance, and rebound insomnia, as
Sleeping pills and sleep eating

Several news reports in 2006 drew attention to a strange
side effect of zolpidem (Ambien): sleep eating. People were
seen foraging for food at night but were unable to remember the episodes in the morning, or they reported finding
evidence of a midnight feast with no recollection of the
event. Several people even gained quite a lot of weight.
Other unusual side effects seen with Ambien and related
drugs include sleepwalking, short-term amnesia, and,
rarely, sleep driving. Some of the driving cases occurred
when people took sleep medication after drinking alcohol.
As a result of these incidents, in 2007 the FDA ordered the
drugs manufacturers to issue strong new label warnings
about the risks of unusual behavior and to produce brochures about safe use.
Although rare, these incidents highlight the need for people
who use sleep medication to be aware of the potential side
effects and to use them properly. Always allow enough
time for sleep, use only as directed, and avoid alcohol. If
you experience any unusual occurrences, talk to your doctor right away.
24
Improving Sleep
well as headache, dizziness, nausea, and, in rare cases,

sleepwalking and sleep eating (see Sleeping pills and
sleep eating, at left). The long-term effects of nonbenzodiazepines remain unknown.
Antidepressants. These medications are neither
approved for insomnia nor proven effective for it.
However, some doctors believe antidepressants have
fewer side effects and are safer for long-term use than
benzodiazepines, and that insomnia is often related
to depression. In addition, antidepressants have fewer
regulatory restrictions than benzodiazepines, so theyre
easier to prescribe. Those most commonly prescribed
for insomnia include trazodone (Desyrel), amitriptyline (Elavil, Endep) and doxepin (Sinequan).
In fact, antidepressants do seem to help some people. Studies of depressed people who also have sleep
problems show that the medication reduces the time it
takes to fall asleep and nighttime arousals. How they
work isnt clear, but sleep may result from a sedative
effect. In addition, the drugs ability to ease anxiety
and mild depression may make it easier for people
with these problems to relax and fall asleep.
The effect of antidepressants on sleep quality varies; in general, they reduce REM sleep but have little
impact on deep sleep. Side effectsnamely dizziness,
dry mouth, upset stomach, weight gain, and sexual
dysfunctionare common. These drugs also can
increase leg movements during sleep. Some people
find certain antidepressants make them feel nervous
or restless, so the medication can actually exacerbate
insomnia. Its not clear if these medications lead to tolerance or rebound insomnia.
Melatonin-receptor agonist. Ramelteon (Rozerem) works by attaching to the same receptors on
the suprachiasmatic nucleus used by the bodys naturally produced melatonin (see page 5). The suprachiasmatic nucleus controls the circadian cycle of sleep
and wakefulness. Ramelteon has a more potent effect
than ingested melatonin, which helps some people fall
asleep faster and can be used to change the circadian
sleep phase. The drug is approved to treat insomnia
for people who have trouble falling asleep at bedtime.
Ramelteons most common side effect is dizziness, and it may also worsen symptoms of depression.
People who have severe liver damage or who use the
sea and, more rarely, fast or irregular heartbeat, blurred

vision, or heightened sensitivity to sunlight. Complications are generally more common in children and people
over age 60. Diphenhydramine blocks the brain chemical acetylcholine, which is essential for normal brain
function. A study that pooled findings from 27 studies on the effect of medications like diphenhydramine
found that elderly people who took these drugs faced
a higher risk of cognitive problems, including delirium. Alcohol heightens the effect of these medications,
which can also interact adversely with some drugs. If
you take nonprescription sleeping
pills, be sure to ask your physician
about the possibility of interactions
with other medications.
But be aware that sleep experts
generally advise against using these
medications, largely because of
their side effects but also because
they are often ineffective in relieving sleep problems. Furthermore,
there is no information about the
safety of taking such medications
Many nonprescription sleep aids contain
antihistamines such as diphenhydramine.
over the long term.
antidepressant fluvoxamine (Luvox) shouldnt take it.

Ramelteon has a short half-life of two to five hours.
Citing clinical studies that found ramelteon did not
cause tolerance, dependence, or rebound insomnia, the
drugs manufacturer promotes it for long-term use.
The drug may be more likely to benefit older rather
than younger people, since people produce less melatonin as they age. However, older peoples primary sleep
problem tends to be waking up during the night, not
falling asleep at the beginning of the night, suggesting
ramelteons usefulness may be limited. More studies
and clinical experience should help
clarify the picture.
Over-the-counter
sleep aids
Drugstores carry a bewildering

variety of over-the-counter sleep
products, and theres clearly a market for such products. One small
survey of people ages 60 and over
found that more than a quarter had
taken nonprescription sleeping aids
in the preceding yearand that one
in 12 did so daily. But do these products work? And
if you try them, should you choose a sleeping pill, an
herbal remedy, a dietary supplement, or a mechanical
device?
Standard nonprescription sleeping pills

Behind the riot of competing brands, this class of
products is surprisingly straightforward. Each one
whether a tablet, capsule, or gelcapcontains an
antihistamine as its primary active ingredient. Most
over-the-counter sleep aidsincluding Nytol, Sominex, and otherscontain 25 to 50 milligrams (mg)
of the antihistamine diphenhydramine. A few, such
as Unisom SleepTabs, contain 25 mg of doxylamine,
another antihistamine. Othersincluding AspirinFree Anacin PM and Extra Strength Tylenol PM
combine antihistamines with 500 mg of the pain
reliever acetaminophen.
Over-the-counter antihistamines have a sedating
effect and are generally safe. But they can cause nauwww.h e a l t h . h a r v a r d . e d u
Dietary supplements
A 2007 survey reported that about 1.4% of adult
Americans had used some form of alternative medicine (mostly herbal supplements) for insomnia or
trouble sleeping.
As with other dietary supplements, the FDA does
not regulate these products, so they arent tested for
safety, effectiveness, quality, or accuracy of labeling.
Although marketed as natural, these products may
contain biologically active substances that can have
side effects or interact with other medications or supplements. If youre thinking about using such products
(or already do so) be sure to tell your doctor.
Many herbal products include a variety of active
ingredients, some of which might interact unfavorably with other medications youre taking. Even a single
herb is a complex chemical stew. Valerian root extract,
for example, contains more than 100 specifically identified substances. Researchers dont know precisely which
of these accounts for the herbs effect, nor can they say
Improving Sleep
25
Mechanical devices
Specially designed orthopedic pillows may help people
with insomnia sleep better. For people with sleep problems due to snoring or nasal congestion, adhesive-backed
nasal strips (such as Breathe Right) or devices such as
NoseWorks, a small plastic nasal support, may provide
relief. Manufacturers contend that such products help
keep nasal passages open, reduce snoring, and increase
airflow, thus improving sleep. But little independent research has evaluated these claims, and many people who
try them find they dont work.
exactly how they might interact with other medications.

Finally, the per-dose price of these remedies varies far
more than that of standard sleeping pills.
Scientific understanding of these substances is limited, and what we know generally comes from small,
short-term studies. Thus, most doctors discourage the
use of herbal medicines as sleep aids. But the market
for such products is booming. Readily available alternative sleep remedies include the following:
Valerian (Valeriana officinalis). A few studies suggest that valerian is mildly sedating and can help
people fall asleep and improve their sleep quality.
However, a review in the Journal of Clinical Sleep Medicine pointed out that most of the studies were small
and flawed, and that even the positive studies showed
only a mild effect. The most common reported side
effects are headaches, dizziness, itching, and gastrointestinal disturbances.
As with other unregulated remedies, the quality of
valerian-containing products varies widely. A report by
ConsumerLaba commercial laboratory that periodically tests the quality of herbal remediesfound that
nearly a quarter of valerian-based products appeared to
contain no valerian whatsoever, and an equal number
had less than half the amount claimed on their labels.
26
Improving Sleep
Chamomile. Tea made from this flower, a member
of the daisy family, is a traditional remedy long used to

help people relax and become drowsy. Chamomile is
both mild and safealthough rare allergic reactions,
including bronchial constriction, can occur. If youre
allergic to plants in the daisy family, which includes
ragweed, you should probably avoid this herb. There
are no scientific studies showing chamomile is effective in treating insomnia.
Synthetic melatonin. The brains production of
the hormone melatonin peaks in the late evening, in
conjunction with the onset of sleep. Since the 1990s,
a synthetic version has been widely available in the
United States as a supplement at health food stores
and pharmacies. In Great Britain and Canada, melatonin is classified as a medicine and available by prescription only.
Despite some initial enthusiasm for synthetic
melatonin, most subsequent research has been disappointing, finding either minimal benefits or none at
all. A 2004 review of the melatonin research by the
federal Agency for Healthcare Research and Quality
(AHRQ) concluded that the supplement is not effective in treating most sleep disorders.
However, a subset of people do appear to benefit: those whose insomnia results from delayed sleep
phase syndrome (see page 40), a circadian rhythm disorder in which people dont start to feel sleepy until
hours after the traditional bedtime. The AHRQ review
found that melatonin enables people with this disorder to fall asleep an average of nearly 40 minutes faster
than they would with a placebo.
Melatonin has a short half-life (one or two hours)
and does not appear to pose any major health risks
when taken for a short time. The most commonly
reported side effects are nausea, headache, and dizziness. Its long-term effects are unknown.
Breathing disorders in sleep
lthough relaxed and steady breathing is natural

for most sleepers, some people snore so loudly
that they literally wake the neighbors. Loud snoring
may be a sign of sleep apnea, a life-threatening condition marked by frequent interruptions in breathing.
In most cases, however, people who snore only suffer from simple snoring produced when the muscles
of the airways relax during sleepa condition that
doesnt cause medical complications but may disrupt
others sleeping nearby.
Snoring
With the onset of sleep, muscles in the airway relax

and the airway narrows. Snoring occurs when the
airway narrows too much, causing turbulent airflow.
This, in turn, makes the surrounding tissue vibrate,
producing noise. More than one-third of adults in one
survey said they snored at least a few nights a week in
the previous year.
When a persons nasal passages are swollen by a cold,
allergies, or a reaction to smoking, temporary snoring
may occur. For someone with a deviated septum, the
problem is ongoing. A particularly large uvula; enlarged
tonsils, adenoids, or tongue; an elongated soft palate; or
a very small jaw may also contribute to snoring.
In yet other people, excess fat in the neck area
may reduce the width of the air passage and promote
snoring. The hormones progesterone and estrogen
may play a protective role; before menopause, women
snore less than men, but snoring increases among
women later in life. Many women snore late in their
pregnancies, a phenomenon attributed to hormonerelated swelling of airway tissues.
Although snoring is rarely life-threatening, sleep
specialists take even simple snoring seriously. A person who snores heavily deserves a thorough examination of the throat, mouth, palate, tongue, and neck and
may need to undergo sleep studies.
Treatments for snoring

Hundreds of devices are marketed as aids for people
who wish to stop snoring or improve their nighttime
breathing. Some encourage you to sleep on your side;
others are dental appliances that try to keep your airway open by preventing your tongue from falling back
or by moving your jaw forward. Check with your physician before investing in such a breathing device. He
or she may be able to recommend simple, inexpensive
ways to prevent snoring.
For example, some people snore only when lying
on their backs and can be encouraged to lie on their
sides by having a tennis ball or golf ball sewn into
the back of their pajamas (which makes back sleeping uncomfortable). Others keep air passages open by
raising their heads with an extra pillow or by propping
up the head of the bed a few inches.
Doctors usually encourage overweight snorers to lose weight. It may also help to quit smoking,
forgo alcohol in the evening, and avoid sleeping pills
or tranquilizers, which slow breathing and decrease
muscle tone.
If swollen nasal tissues are the problem, a humidifier or medication may reduce swelling. An operation may be necessary to correct a deviated septum or
remove large tonsils and adenoids. In extreme cases,
physicians may recommend more extensive surgery,
similar to that used to treat sleep apnea.
Laser surgery. In 1990, a French physician
reported successfully treating snoring with a type of
laser surgery called laser-assisted uvulopalatoplasty
(LAUP). Some ear, nose, and throat specialists in
the United States use the procedure, which is done
on an outpatient basis. In this surgery, the physician
uses a carbon dioxide laser to shorten the uvula and
to make small cuts in the soft palate on either side of
the uvula. As these nicks heal, the surrounding tissue
pulls tighter and stiffens. Because snoring results from
the flapping of loose tissue at the back of the soft palImproving Sleep
27
ate, it is less likely to occur when the tissue is smaller

and stiffer. The procedure, done under local anesthesia, causes little bleeding. Patients usually have a sore
throat for about a week. After five weeks of healing,
the treatment may be repeated if snoring persists.
Three or four procedures may be needed.
LAUP is not considered an essential therapy and
may not be covered by insurance. Also, while LAUP
can be quite effective in stopping snoring, the technique doesnt appear to ease apnea. In fact, this procedure can be dangerous for people with apnea because
it removes the warning signal of this breathing disorder. Therefore, be sure you have a physician rule out
sleep apnea before undergoing LAUP.
Somnoplasty. Another treatment for snoring is
somnoplasty, or radiofrequency tissue volume reduction, developed by ear, nose, and throat specialists
at Stanford University. In the mid-1990s, the FDA
approved this procedure as a treatment for snoring; since then, its become a treatment option for
obstructive sleep apnea. Somnoplasty is performed
on an outpatient basis using a local anesthetic. The
doctor delivers radiofrequency waves through the
tips of tiny needles inserted into the obstructive tissue to shrink it. Somnoplasty only takes a few minutes to perform and doesnt cause bleeding, but it may
have to be repeated to achieve results. People typically
experience some swelling immediately following the
procedure; over-the-counter painkillers can usually
control any pain.
Palatal implants. In 2004, the FDA approved this
procedure (also known as the Pillar procedure) in
which up to three matchstick-sized stiffening rods
made of polyester are implanted into the soft palate.
The rods help prevent collapse of the palate, limiting
obstruction of the back of the nose when a person
falls asleep. The procedure, done under local anesthesia in an office, is reversible. If it causes pain or
does not work, the rods can be removed, again under
local anesthesia in the office. Sometimes the rods
come out on their own, but without significant discomfort. If palate collapse is the main reason for the
snoring, then the procedure may improve the symptoms; it has limited benefit if other anatomical problems are involved.
28
Improving Sleep
Sleep apnea
Sleep apnea is a life-threatening condition in which
breathing stops or becomes shallower hundreds of
times each night. By far the most common form is
obstructive sleep apnea (OSA), in which the airway
becomes blocked during sleep.
Untreated, sleep apnea can have serious conse
quences. The relentless daytime fatigue that often
results may lead to failed careers, broken marriages,
and automobile and workplace accidents. It can even
be life-threatening, leading to the development of hypertension, heart failure, and stroke. A New England Journal
of Medicine study found sleep apnea doubles a persons
risk of stroke over a seven-year period. Sleep apnea can
wreak havoc on the cardiovascular system because the
heart must work harder every time the person arouses
to open his or her airway (see Heart disease, page 12).
Sleep apnea used to be considered uncommon,
and it often remained undiagnosed. Physicians rarely
checked for it except in the stereotypical patientan
overweight, middle-aged man who snored. Although
more than half of the estimated 18 million Americans
who have sleep apnea are overweight, many are not.
The disorder affects about one in 25 middle-aged men
and one in 50 middle-aged women, and the incidence
rises with age. At least one in 10 of those older than 65
has sleep apnea.
Obstructive sleep apnea

Obstructive sleep apnea (OSA) occurs when the upper
airway is blocked by excess tissue such as a large uvula,
the tongue, the tonsils, fatty deposits in the airway
walls, nasal congestion, or a floppy rim at the back of
the palate. People with OSA tend to have smaller airway openings than those who dont. A narrow airway
makes obstruction all the more likely when airway
muscles relax at the onset of sleep.
A potentially life-threatening lack of oxygen and
buildup of carbon dioxide, as well as increasing efforts
to breathe, cause the sleeper to wake and gasp loudly
for air until blood oxygen levels return to normal. At
worst, a person with OSA cannot breathe and sleep at
the same time.
Some people with OSA repeat this cycle hundreds
of times a night without being fully aware of what is
happening. They dont realize how little sleep theyre

actually getting and may routinely feel sleepy. Others
wake up after bouts of apnea and have difficulty getting back to sleep; they reason that insomnianot a
breathing problemmakes them sleepy during the
day. The condition can become even more perilous if
a person with OSA uses substances that further relax
airway muscles or suppress arousal or breathing, such
as muscle relaxants, alcohol, and some sleeping pills.
Symptoms and signs of OSA are as follows:
S noring. Although many snorers have no medical
problems, the hallmark of OSA is frequent snoring
that is loud enough to disturb a bed partner. The
snorer may choke, gasp, or appear to hold his or her
breath during sleep.
Th
ick neck. Men with a neck circumference of 17
inches or more and women with a neck circumference of 16 inches or more are at higher risk. As with
snoring, obesity is a major risk factor, since fatty
deposits surrounding the throat expand as people
gain weight, narrowing the airway.
Hypertension. More than half of patients with OSA
have high blood pressure. Research has shown that
OSA is a cause of hypertension.
Grogginess, fatigue, and sleepiness. People with
OSA are excessively sleepy during the day and have
two to six times as many traffic accidents as individuals without this condition.
OSA occurs on a spectrum from a wide-open airway (that is, no problem) to a completely blocked airway (see Figure 6). In some cases, the airway is only
slightly narrowed, but people must work extra hard to
inhale, although they have no significant drop in blood
oxygen levels. This extra work wakes them up many
times each night, and they may complain of insomnia
or daytime sleepiness. The same treatments that help
individuals with a fully closed airway are also effective
for these cases.
Treatments for obstructive sleep apnea

Treatments for OSA fall into four general categories
lifestyle changes, air pressure devices, dental devices,
and surgery. In addition, medication may be used
along with these treatments.
Lifestyle changes. Weight loss is the best treatment
for weight-related OSA, but it doesnt always cure the

problem (see Weight-loss surgery for apnea? on
page 32). Sleeping on ones side instead of the back can
work for people who have OSA only while sleeping on
their back. Everyone with OSA should avoid alcohol,
sedatives, and muscle relaxants. Nasal strips, mechanical dilators, and moisturizing gels and sprays have not
been shown to help. Because weight loss takes time
and can be very hard to achieve and maintain, and
because other simple measures are usually not sufficient for more severe cases, additional treatments are
often required.
Positive airway pressure. The first-line therapy for
most people with moderate to severe OSA is positive airway pressure (PAP), the use of an air-pressure
device connected by a hose to a mask that covers the
Screening for sleep apnea

This six-question test can help you and your physician
determine if you need to be tested for sleep apnea.
Do you snore on most nights (more than three
times per week)? Yes2 No0

Is your snoring loud (can it be heard through a
door or wall)? Yes2 No0

Has anyone ever told you that you stop breathing
or gasp during sleep?

Never0 Occasionally3 Frequently5
What is your collar size?
Men: less than 17 inches0 17 inches or greater5

Women: less than 16 inches0 16 inches or greater5
Have you had, or are you currently being treated
for, high blood pressure? Yes2 No0

Do you occasionally doze or fall asleep during
the day when:

You are not busy or active? Yes2 No0
You are driving or stopped at a light? Yes2 No0
Score
9 points or more: See your physician or a sleep
specialist to assess the need for a sleep study.
68 points: Uncertain; physician must use clinical
judgment.
5 points or less: Low probability of sleep apnea.
Reprinted with permission from Dr. David White, Sleep Health Centers,
Boston, Mass.
Improving Sleep
29
nose. The air pressure delivered through the mask

opens the airway, preventing collapse when muscles
relax during sleep and allowing the person to sleep
normally and breathe regularly without interruption.
Figure 6 Treating apnea with CPAP

Nose
Air flow
Mouth
Hard palate
Soft palate
Pharynx
Blocked
airway
In a person with obstructive sleep apnea, the upper airway

which includes the nose, mouth, and throatis blocked. In the
example above, excess fatty tissue around the palate and pharynx
is the culprit, but the blockage can occur anywhere along the airway. As a result, air cant enter the lungs, and the resulting drop
in oxygen signals the brain to send an emergency Breathe now!
signal that briefly awakens the sleeper and makes him or her gasp
for air. These pauses in breathing can last seconds to minutes and
can occur up to 100 times per hour.
From CPAP machine
CPAP mask
Restored
air flow
Opened airway
A CPAP machine delivers continuous positive pressure via a mask

that covers the nose, which prevents the collapse of the airway
when the muscles relax during sleep. This allows the person to
sleep normally without interruption.
30
Improving Sleep
The most common form of PAP is continuous positive airway pressure (CPAP), in which the air pressure
stays the same while breathing in and out.
CPAP was once quite cumbersome but has
become more comfortable. Newer models are lighter
and quieter, and many offer options such as warmed
humidified air (which alleviates nasal congestion,
skin dryness, and dry mouth) and a timer that slowly
builds up pressure to give you time to adapt and fall
asleep more easily. There are also a variety of mask
styles, allowing users to find the one that best fits the
face and is most comfortable.
People usually try CPAP for the first time in a
sleep laboratory, so a technician can adjust the pressure during sleep. Many people adjust to it without any
problem and report that their night in the laboratory
is the best nights sleep theyve had in years. Others
find it difficult at first to breathe out against a constant
stream of air and to sleep with their mouth closed, but
they usually get used to it with time.
CPAP generally leads to a great improvement in
the amount of time spent in restorative deep sleep,
which improves alertness the next day. In many cases,
CPAP also reduces or eliminates hypertension. For
some people, CPAP is a lifelong treatment.
For people who have difficulty exhaling against the
pressure of CPAP, a refinement called bilevel PAP (often
referred to by the trademarked name BiPAP) may be
more tolerable. It delivers air under higher pressure
as the sleeper inhales and switches to a lower pressure
during exhalation to make it easier to breathe out. An
important innovation (called AutoPAP) is the inclusion
of an internal regulator that moves the pressure up and
down, rather than staying at a fixed setting, depending
on your pressure needs at any particular moment.
Dental devices. Oral appliances that reposition
the lower jaw and tongue, permitting the airway to
remain open, are fairly well tolerated and have a success rate of 50% to 70% for mild to moderate OSA.
They are less successful with severe OSA.
These devices are less cumbersome and easier to
travel with than CPAP. However, they can cause shifting of teeth and problems with the temporomandibular joint, so be sure to get the device from a dentist
trained in managing OSA patients and get regular folwww.health.har vard.edu
low-ups, including a sleep study done with the device

in place to make sure it eliminates the OSA.
Surgery. Most surgical procedures for sleep
apnea do not have good success rates. Although some
patients improve, a sizable percentage of patients
dont get better, and some patients symptoms actually worsenthat is, they have more episodes of apnea
after the surgery than they had before.
Whats behind these poor success rates? Surgeons
must deal with a long soft tube of tissue that can collapse at any pointor even at several pointsand they
cant always predict exactly where it might collapse in
the future. Surgery corrects collapse at a single spot, so
if a collapse later occurs at a different spot or in several
spots, OSA can return.
Thats not to say surgery is always a bad idea. If
you have OSA, consult with a sleep specialist to review
all your options. Then, if you decide on surgery, find
a surgeon who has a lot of experience with these procedures to improve your chances for success. Types of
surgery for OSA include the following:
Uvulopalatopharyngoplasty (UPPP). This procedure to remove throat tissue helps about 40% to 45%
of people with OSA. The rest may need to have further upper airway surgery or use PAP.
Somnoplasty. Somnoplasty (see page 28) is sometimes used to treat mild OSA when other treatments
have not helped. There are limited data supporting
its use.
Corrective jaw surgery. Surgery to move the upper or
lower jaw forward may enlarge the upper airway for
some people with OSA. Centers with specialists in
this procedure report success rates up to 90%. However, the procedure requires extensive training and
experience. The procedure changes the facial appear-
Table 4 Medications for sleep apnea

Side effects
Comments
Obstructive sleep apnea (medications are used with other therapies)

SSRI antidepressants*
fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
Upset stomach, nightmares, dry mouth,

decreased sexual function
Minimally effective.
Tricyclic antidepressants*
amitriptyline (Elavil)
clomipramine (Anafranil)
desipramine (Norpramin)
imipramine (Tofranil)
nortriptyline (Aventyl, Pamelor)
protriptyline (Vivactil)
Blurred vision, confusion, constipation,

decreased sexual function
Minimally effective.
Stimulants
modafinil (Provigil)
armodafinil (Nuvigil)
Headache, upset stomach, nervousness
Approved to treat residual daytime sleepiness

after treatment with positive airway pressure;
does not treat apnea itself.
Central sleep apnea (medications are first-line treatments)

acetazolamide (Diamox)*
Tingling in arms and legs; nausea, vomiting,

or diarrhea; changes in hearing; loss of
appetite
Not to be used if allergic to sulfa drugs; not

to be used in conjunction with high doses of
aspirin; should not be used by people with a
history of kidney stones.
theophylline (Theo-24, Uniphyl)*
Heartburn, vomiting, rash
Should be used with caution by people with

a history of convulsions, heart failure, or liver
disease.
oxygen
Nasal dryness and irritation
Eliminates apnea in some patients; also used

in obstructive sleep apnea.
*Although the FDA has not approved drugs in this class for sleep apnea, physicians have found that they sometimes help people with this condition and therefore prescribe them.
Improving Sleep
31
ance and teeth alignment and requires an extensive

recovery period.
P
alatal implants. Some specialists have started using
palatal implants (see page 28) to treat people whose
OSA results from an elongated soft palate. Its not yet
clear what percentage of patients benefit or how long
improvements last.
Medications. Medications for OSA (see Table 4) are
used primarily in conjunction with other treatments.
Antidepressants. Certain antidepressants slightly

improve airway muscle tone and are helpful for a small
percentage of people with mild OSA. Two classes of
antidepressants are used: tricyclics and SSRIs.
Oxygen. Supplemental oxygen, administered through
tubing in the nose, can prevent the drops in blood
oxygen that accompany airway collapse. However,
oxygen does not prevent an airway collapse or sleep
fragmentation, so its used in addition to other
treatments.
Stimulants. Some people with OSA still feel sleepy
during the day even after successful treatment. In
2004, the FDA approved the use of the drug modafinil
(Provigil) for this post-treatment sleepiness. The
drug, which seems to temporarily stop the brain from
making neurotransmitters that promote sleep, was
Weight-loss surgery for apnea?

Bariatric surgery helps extremely obese people lose
weight by reducing the size of the stomach. Initial reports
suggested that the extreme weight loss following the surgery could effectively cure sleep apnea. But subsequent
research revealed that while surgical weight loss can
reduce the severity of sleep apnea and eliminate the condition in some people, others will still have sleep apnea
following surgery and likely need continued treatment.
32
Improving Sleep
originally approved in 1999 to treat sleepiness from

narcolepsy. A related drug, armodafinil (Nuvigil),
was approved in 2007 for sleepiness resulting from
narcolepsy, shift work, and OSA. While both drugs
can help people with OSA who have trouble staying
alert in the day, bear in mind that the drug does not
address the source of the problem and is therefore
used with other treatments, not in place of them.
Central sleep apnea

Central sleep apnea, or CSA, occurs when respiratory
centers in the brain fail to send the necessary messages to initiate breathing. Although the airway isnt
blocked, the diaphragm and chest muscles stop moving. Shortly, falling blood oxygen and rising carbon
dioxide levels set off an internal alarm, triggering the
person to resume breathing (and often waking him or
her as a result). This rare condition warrants a thorough evaluation, including a sleep study, to establish
the underlying cause, which in turn guides treatment.
CSA becomes more common as people age and is
more frequent and severe in those with heart failure,
chronic lung disease, or neurological damage. CSA
doesnt cause snoring, but people with this problem
are usually aware of waking up during the night and
often complain of daytime sleepiness.
Therapy usually involves treating the underlying
medical condition that has disrupted breathing. For
example, if the CSA is caused by heart failure, medications to treat the heart failure may eliminate the CSA.
Some patients use PAP and may also receive added
oxygen. For people who have CSA only as they begin
to fall asleep, a mild sleeping pill may help them fall
asleep and stay asleep, solving the breathing problem.
Medications such as acetazolamide (Diamox) and
theophylline (Theo-24, Uniphyl) benefit some people
(see Table 4).
Movement disorders and parasomnias
Movement disorders
Sleepers typically shift position every 15 to 30 minutes, and its normal for muscles to jerk at the onset
of sleep. But people with certain neurological disorders that trigger excessive limb movements may find it
impossible to obtain a restful nights sleep.
Restless legs syndrome

Restless legs syndrome (RLS) is a neurological disorder characterized by strange sensations in the lower
legs, knees, and occasionally the arms, accompanied
by an uncomfortable urge to move the limbs. Motion
may relieve the discomfort temporarily. RLS affects
about 10% of people ages 30 to 70, two-thirds of
them women.
As many as half of people with RLS note that
other members of their family have similar symptoms, and each child of an affected person has a 50%
chance of inheriting the condition. In 2007, two
research teams identified specific genes linked to the
development of RLS that may account for up to half
of all cases of the disorder.
Sleep deprivation is a major problem for individuals with RLS, as the symptoms are most prominent
at nightor, in many cases, only occur at night. RLS
symptoms may compel the person to get in and out of
bed many times. In recognition of the restless nights
suffered by people with RLS, the nonprofit Restless
Legs Syndrome Foundation titled its newsletter NightWalkers (see Resources, page 48).
During the day, symptoms are worse when sitting
still, and the irresistible urge to move can make it difficult for some people with RLS to take car or plane
trips, enjoy a movie, or even hold a desk job. People

develop a variety of coping strategies, such as pacing, doing knee bends, rocking, or stretching the leg
muscles. Some people get temporary relief by rubbing
or squeezing their leg muscles, wrapping their legs in
bandages, or applying cold or warm compresses. The
daytime symptoms sometimes abate for a few hours,
days, or even years.
Because the symptoms sound bizarre or vague,
and the need to be constantly mobile seems like nervousness, people with RLS are frequently thought
to have psychiatric problems. In the past, they were
often misdiagnosed as having hypochondria, manicdepressive illness, or a stress-related disorder. Children who have RLS are often diagnosed as having
attention deficit hyperactivity disorder. Some people
report that their symptoms started in adolescence and
that adults attributed the problem to growing pains or
back trouble.
RLS usually worsens with age (see Figure 7). Many
people dont seek medical attention until their late 30s.
Women may find that symptoms flare up during men-
Figure 7 Prevalence of restless legs

syndrome by age
6
4
Percentage
leep is not always as quiet and peaceful as wed like

it to be. Some people are troubled by uncontrollable limb movements, while others experience parasomnias (unusual behaviors during sleep).
2029 3039 4049 5059 6069 7079
80+
Age (years)
RLS can occur at any age, but it tends to be more common and
severe in people over 50.
Adapted from Archives of Internal Medicine, June 13, 2005, pp. 128692.
Improving Sleep
33
struation, pregnancy, or menopause. At least one in

four pregnant women experiences restless legs.
Restless legs can be a complication of alcoholism,
iron-deficiency anemia, diabetes, heart failure, or kidney failure. In some people, caffeine, stress, nicotine,
fatigue, or prolonged exposure to a cold or very warm
environment worsens the symptoms. Certain medicationsincluding antihistamines, antidepressants, or
lithiumcan exacerbate RLS.
Periodic limb movement disorder

A neurological condition called periodic limb movement disorder (PLMD) causes people to kick and
jerk their arms and legs throughout the night. Their
leg and arm muscles involuntarily contract about
every 20 to 40 seconds, so the same movement
involving the hip, knee, or anklemay be repeated
hundreds of times a night. These repetitive movements are called periodic limb movements of sleep
and can cause brief arousals. PLMD results when
the movements disrupt sleep enough to produce
daytime sleepiness.
Most people with RLS also have PLMD, but the
reverse is not true. In fact, the two disorders have several key distinctions (see RLS and PLMD: Whats the
difference? below).
RLS and PLMD Whats the difference?

Restless leg syndrome
(RLS)
Periodic limb movement

disorder (PLMD)
Occurs while awake, sometimes

preventing sleep.
Occurs during sleep, causing

partial arousals that disrupt
sleep.
Involves voluntary movements

pacing, knee bends, rocking, or
stretchingperformed to relieve
uncomfortable sensations in
the lower legs and knees. Often
worse after periods of inactivity
and at bedtime.
Involves involuntary movements,

usually repetitive flexing of the
big toe, ankle, knee, and hip,
typically occurring every 20
to 40 seconds. Episodes last
anywhere from a few minutes to
several hours.
People with RLS are aware of

their symptoms, which include
aching, burning, tingling, and
creepy, crawly sensations in
the legs.
Affected people usually arent

aware of their symptoms unless
a bed partner complains.
Diagnosis is based on a patients

description of symptoms.
Diagnosis usually requires a

sleep study.
34
Improving Sleep
According to some estimates, as many as 30% to

50% of people ages 65 and older have PLMD. However,
that figure is based on observations of leg twitches
alone, and not all of these people experience the brief,
unconscious awakenings that disrupt sleep.
Episodes of PLMS may last only a few minutes, or they may continue for hours, with intervals
of sound sleep in between. They usually dont occur
continuously throughout the night, but instead cluster in the first half of the night and occur mainly during non-REM sleep. Instead of proceeding smoothly
through all the sleep stages in regular cycles, people
with PLMD awaken for a few seconds at a time (generally without realizing it) and frequently skip back to
the lighter stages of sleep. Unless a bed partner complains, people with PLMD are often oblivious to the
movements and may wake up baffled at why they feel
exhausted despite getting what they thought was a full
nights rest.
Treatments for movement disorders

Doctors diagnose RLS and PLMD based on the individuals description of symptoms and, in some cases,
observations during an overnight sleep study. Standard neurological examinations often reveal no
abnormality.
Several small studies suggest that exercise can ease
both RLS and PLMD; walking or other moderate exercise, such as biking or swimming, are good choices.
Some people find that cold showers are beneficial,
but others prefer heat. Finally, some people with mild
RLS may be able to get to sleep by simply massaging
their calves or stretching their legs in bed. But most
people with moderate to severe RLS need medication.
Drugs that ease the tremors of Parkinsons disease
also reduce the number of leg movements and thus
improve quality of life for people with RLS and PLMD
(see Table 5). These include bromocriptine (Parlodel),
levodopa-carbidopa (Sinemet), pramipexole (Mirapex),
and ropinirole (Requip), which in 2005 became the
first drug approved by the FDA to treat RLS. Although
the drugs used to treat RLS and PLMD are the same as
those used in treating Parkinsons disease, people with
these sleep disorders are no more likely to develop Parkinsons disease than other individuals.
People with mild movement disorders may be

prescribed clonazepam (Klonopin) or temazepam
(Restoril), which may help them stay asleep during
leg movements. Most people who take these medications for insomnia develop a tolerance to them after a
few weeks, but this doesnt seem to happen when such
drugs are taken for RLS.
Opiates (opium-derived drugs) such as oxycodone
(OxyContin) may be used to treat people with severe
RLS symptoms who dont respond to other treatments. Opiates decrease the discomfort of RLS and,
for some, dramatically reduce leg movements at night.
But because of the potential for addiction, most physicians are reluctant to treat sleep disturbances with
these drugs. However, when properly used, they may
provide long-term benefit with little risk of addiction.
Parasomnias
People with parasomnias may wake up enough to

carry out complex behaviors, but not enough to realize
what they are doing. These sleep-disrupting behaviors
include sleepwalking, sleep eating, and night terrors,

among others.
Somnambulism and somniloquy

Somnambulism, or sleepwalking, occurs during partial awakening from deep sleep. Sometimes sleepwalkers carry out complex actions; at other times they
simply pace or sit on the edge of the bed performing
repetitive behaviors. They can be difficult to awaken
and typically have no memory of the episode in the
morning. There have been reports of somnambulists
committing murder, although this is extremely rare.
Episodes of sleepwalking are usually brief and benign,
with few people endangering themselves or others.
Scientists used to believe that sleepwalkers were acting out their dreams, but experts have determined that
sleepwalking does not occur during dreaming.
Sleepwalking is common in children and probably occurs because their brains have not yet mastered
regulation of sleep and waking. The tendency seems
to be inherited. Although people are more likely to
sleepwalk when theyre anxious or fatigued, there is
Table 5 Medications for movement disorders

Side effects
Comment
Clumsiness or unsteadiness, dizziness,

lightheadedness, daytime drowsiness,
headache
Should be used with caution by people with sleep

apnea or other breathing difficulties; not to be used
with alcohol or other depressants; habit-forming;
withdrawal symptoms may occur if stopped abruptly.
Abnormal movements, depression, mental

changes, nausea, dizziness
Certain drugs in this class should not be used by

people who are sensitive to ergot drugs, who have
hypertension, who take monoamine oxidase inhibitors
(MAOIs), or who have glaucoma.
Depressed breathing and circulation, dizziness

or lightheadedness, next-day sedation,
constipation, nausea, vomiting
Risk of addiction; not to be used by persons with

sleep apnea; should not be used with alcohol or other
depressants.
Unsteadiness, vision problems, body aches,

congestion
Tegretol may reduce the number of blood cells

produced by your body.
Benzodiazepines
clonazepam (Klonopin)
temazepam (Restoril)
Dopamine agents
bromocriptine (Parlodel)
levodopa-carbidopa (Sinemet)
pramipexole* (Mirapex)
ropinirole* (Requip)
Opiate
oxycodone (OxyContin, Percocet)
Anticonvulsants
carbamazepine (Tegretol)
gabapentin (Neurontin)
valproic acid (Depakene)
*Ropinirole and pramipexole are FDA-approved to treat RLS. Other medications in this chart are not approved to treat RLS or PLMD, but physicians have found that they
help people with these conditions.
Improving Sleep
35
little correlation between somnambulism and psychological problems. If the condition continues beyond
puberty, the individual should be evaluated to determine whether sleepwalking is the result of nighttime
epilepsy or a reaction to medication, extreme stress, or
another sleep disorder. If the condition presents a risk
of injury, a doctor may prescribe medications such as
benzodiazepines.
Somniloquy, or talking in ones sleep, is nothing
to worry about. People are more likely to talk in their
sleep during times of stress or illness. Talking can
occur during any or all stages of sleep. When awakened, people who talk in their sleep rarely remember
what they said. Only occasionally can someone who
talks in his or her sleep hear and respond to what
someone else says.
Nocturnal eating disorders

The two types of nighttime eating disorders are nocturnal eating syndrome and sleep-related eating disorder.
Nocturnal eating syndrome occurs most commonly
in people with daytime eating disorders or depression.
They are usually light sleepers and wake frequently.
Within minutes after getting out of bed, people with
this condition raid the refrigerator and begin wolfing
down food. Although they arent really hungry, they
cant go back to sleep without eating. In some people
with this disorder, overeating occurs only during sleep
hours, not during the daytime. The person is awake
and fully alert during the episode and can recall it
the next day. Nocturnal eating syndrome should be
treated as an eating disorder.
Sleep-related eating disorder is a combination of a
sleep disorder and an eating disorder. People with this
disorder experience partial arousals similar to sleepwalking, but respond by eating. Often they consume
unhealthful, high-calorie food, such as cookie dough.
They report being half-awake or asleep during the episodes and have very poor memory of the events or no
recollection at all. Sleep-related eating disorder occurs
more frequently in people with eating disorders and
depression. However, treatment should address both
the sleep disorder and the existing eating disorder.
Sleep-related eating disorder occurs in children
and adults and sometimes can be traced to an illness
36
Improving Sleep
or traumatic event. A medical evaluation may reveal

an ulcer, a history of strict dieting, bulimia, or a sleep
problem such as narcolepsy, sleepwalking, sleep apnea,
or periodic limb movement disorder. Sometimes medications prescribed for depression or insomnia can
cause this disorder. A number of medicines have been
tried to treat these disorders, including dopaminergic
agents, anticonvulsants, antidepressants, and opiates,
but results have been mixed.
Bedwetting
Bedwetting, known medically as sleep enuresis, is common among children. Its considered a problem, however, if its still occurring by age six. Statistically, 80%
to 85% of children are consistently dry throughout the
night by age 5. After that, the number of children who
continue to wet the bed decreases by about 15% per
year, even without treatment, and only 1% to 2% of
children still wet the bed by the time theyre 15. Almost
all bedwetting children eventually stay dry at night.
Bedwetting, which occurs more frequently among
boys than girls, is usually due to slow maturation of
bladder control. Occasionally, it results from psychological stress. When a specific physical problem such
as a structural abnormality of the urinary tract, diabetes, a urinary tract infection, or a nervous system
defect leads to bedwetting, the child will also have difficulty with daytime bladder control.
Its important for adults to understand that, initially, children have little control over bedwetting and
that admonishments and punishments wont solve the
problem. Parents should remain calm as they change
the bed sheets and underpants. Dont show disgust or
disappointment.
Reminding the child to urinate before going to bed
and limiting liquids in the last two hours before bedtime
may reduce or eliminate the problem. Other options
include setting up a token-and-reward system to motivate the child to stop wetting the bed; using an alarm
that wakes the child upon the first sign of wetness; bladder training exercises; and, as a last resort, medications.
Consult your pediatrician for further details.
Bedwetting occurs in a very small percentage
of adults and is often due to an underlying medical
problem or excessive caffeine or beer consumption. In
men, an enlarged prostate gland that presses against

the bladder may be to blame. Bedwetting may be a
side effect of diuretic pills or a sign of diabetes, a bladder or kidney problem, epilepsy, or serious obstructive
sleep apnea. Treatment for adult bedwetting depends
on the cause.
REM sleep behavior disorder

Most people make subtle twitching movements during
REM sleep, but occasionally sleepers shout, punch, or
otherwise act out their dreams. This phenomenon
known as REM sleep behavior disorderwas identified in the 1980s. Its estimated to occur in one in 200
people (0.5%), and nine out of 10 people who have it
are men. The disorder nearly always arises after age
50, but there are occasional reports of it occurring in
younger adults and children.
Approximately 70% of people with REM sleep
behavior disorder go on to develop Parkinsons disease,
suggesting that similar brain structures are involved in
both conditions.
If the person is at risk of harming himself or others or is having daytime sleepiness from the sleep disruption, a medium-acting benzodiazepine may help
suppress symptoms. Until the problem is under control, people can protect themselves and loved ones
by sleeping in a separate room and putting sharp or
breakable objects out of reach.
Nightmares, sleep terrors, and panic attacks
Nightmares, sleep terrors, and sleep-related panic
attacks can interrupt sleep.
Nightmares. Nightmares, which usually occur
early in the morning, are bad dreams that become
so threatening that a person wakes in a state of fear
and agitation. Nightmares occur mainly during REM
sleep, when the body barely moves.
Nightmares can be a side effect of certain medications, such as antidepressants, narcotics, and barbitu-
rates. Nightmares can also occur when a person stops

taking drugs that temporarily reduce REM sleep, such
as benzodiazepines. Alcoholics who stop drinking
often experience dream disturbances and nightmares.
If you experience frequent nightmares that arent
linked to medication use, counseling may help. The
most common approach is a type of behavioral therapy
known as desensitization, in which the sufferer recalls
the details of the nightmare and uses relaxation techniques to overcome fear. The therapist may guide you
through typical dream sequencesfor example, helping you imagine confronting or driving off a pursuer. A
psychoanalytically oriented therapist, on the other hand,
may focus on identifying and resolving past and present
emotional issues that play themselves out in nightmares.
Sleep terrors. A sleep terror can be quite dramatic
to witness. The sleeper may let out a bloodcurdling
scream, sit bolt upright, and attempt to fight or flee.
During an episode, which may last as long as 15 minutes, a person may seem confused and agitated. After
the spell is over, he or she is likely to go right back to
sleep and later may not remember what happened.
Unlike nightmares, sleep terrors occur during
non-REM sleep, usually in the first hour or so after
going to bed. They appear to run in families and occur
most often in children. Adults with sleep terrors tend
to be more agitated, anxious, and aggressive than
children who have this problem. When the episodes
involve violent or injurious behavior, medical treatment may be recommended. Some doctors prescribe
medications such as benzodiazepines that suppress
deep sleep. Hypnosis or a relaxation technique known
as guided imagery may also be helpful.
Sleep-related panic attacks. People with this condition awaken suddenly because of episodes of intense
panic characterized by a racing heartbeat, sweating,
trembling, breathlessness, or the feeling that they may
be dying. Anti-anxiety drugs are often useful for both
daytime and nighttime attacks.
Improving Sleep
37
Narcolepsy
arcolepsy is a disorder of sleep/wake regulation

whose hallmark is daytime sleepiness. A variety of
other symptoms may also be present, but abnormalities of REM sleep seem to underlie each one. Instead of
occurring normallyafter a steady progression through
the other stages of sleepREM sleep or features of REM
sleep intrude at unusual and unwelcome times, such as
immediately after sleep begins, as soon as a person lies
down, or even in the midst of daytime activities.
About one in 2,000 people has this condition. It
affects both sexes and all races equally, and it has a
genetic component; having a close relative makes a
person 20 to 40 times more likely to have it.
Narcolepsy usually becomes apparent during
adolescence or young adulthood, although symptoms
sometimes appear in early childhood or middle age.

On average, it takes five years of symptoms and visits to
five physicians before a diagnosis of narcolepsy is made.
This is because sleepiness may be the only symptom,
or cataplectic attacks (see Cataplexy, page 39) may be
misdiagnosed as epilepsy or fainting.
In the late 1990s, researchers discovered that many
cases of narcolepsy result from the lack of a brain
chemical called hypocretin (sometimes called orexin)
that normally maintains wakefulness and helps regulate sleep. People with narcolepsy lose the cells that
make hypocretin. The discovery of the gene that
makes hypocretin and the location of its production in
the brain has spurred research focused on new ways to
diagnose and treat this disorder. In 2009, researchers
Table 6 Medications for narcolepsy

Use
Side effects, comments
dextroamphetamine (Dexedrine,
Adderall)
methylphenidate (Ritalin,
Metadate, Concerta)
To counter daytime sleepiness
Nervousness, insomnia, loss of appetite, nausea, dizziness, irregular

heartbeat, headaches, changes in blood pressure and pulse, weight loss.
Potential for abuse. Should not be used by people who take monoamine
oxidase inhibitors (MAOIs) or who have glaucoma.
modafinil* (Provigil)
armodafinil* (Nuvigil)
To counter daytime sleepiness
Anxiety, headache, nausea, nervousness, insomnia. Less potential for

abuse than other stimulants.
To prevent cataplexy and other

REM-related symptoms
Dizziness, dry mouth, blurred vision, weight gain, constipation, trouble

urinating, drowsiness, disturbance of heart rhythm. Should not be used
with MAOIs or during immediate recovery from heart attack.
To prevent cataplexy and other

REM-related symptoms
Nausea, dry mouth, headache, loss of appetite, nervousness, diarrhea or

constipation, sweating, and sexual problems. Should not be used with
MAOIs.
To prevent cataplexy, improve

nighttime sleep, and reduce
daytime sleepiness
Abdominal pain, chills, dizziness, abnormal dreams, drowsiness, stomach

discomfort. Must be taken at bedtime and again during the middle of the
night. Potential for abuse.
Stimulants
Tricyclic antidepressants
clomipramine (Anafranil)
desipramine (Norpramin)
imipramine (Tofranil)
protriptyline (Vivactil)
SSRI antidepressants
fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)
Anticataplectic
sodium oxybate (Xyrem)*
*Modafinil, armodafinil, and sodium oxybate are FDA-approved to treat narcolepsy symptoms. Other medications in this chart are not, but physicians have found they
often help people with narcolepsy and therefore prescribe them.
38
Improving Sleep
reported a link between narcolepsy and variations in

a gene that controls immune function. They speculate
that the loss of hypocretin-producing cells may stem
from an autoimmune process, in which the body mistakenly attacks itself.
Symptoms of narcolepsy
Narcolepsy may manifest in any of several ways:

Excessive sleepiness. People with narcolepsy
struggle to stay awake during the day, and often have
great trouble completing tasks.
Sleep attacks. A person may suddenly fall asleep
for five to 10 minutes when relaxing or even while carrying on a conversation. If REM sleep and dreaming
occur immediately, the person sometimes makes conversation that is appropriate to the dream instead of
the actual situation.
Cataplexy. A person may suddenly lose muscle
tone while awake, causing the head to fall forward and
the knees to buckle. Most attacks last for less than 30
seconds and may go unnoticed, but in severe cases,
the person may fall and stay paralyzed for as long as
several minutes. Laughter, anger, or other strong emotions often trigger cataplexy, which occurs when the
brain mechanism that paralyzes muscles during REM
sleep becomes activated.
Sleep paralysis. A terrifying feeling of paralysis
may occur during the transition between wakefulness
and sleep if the REM stage begins before a person is fully
asleep. Although muscle control usually returns within a
few minutes, such episodes can cause great anxiety.
Hypnagogic hallucinations. When REM dreaming
occurs during wakefulness, the vivid and often frightening images, known as hypnagogic hallucinations,
are difficult to distinguish from reality. A person may
see prowlers or believe that his or her house is on fire.
This usually happens just at sleep onset or upon awakening. This condition can be confused with mental
illness because its symptoms resemble those of some
psychotic disorders.
Disturbed nighttime sleep. Just as sleep intrudes
during the day, unwelcome awakenings can occur at
night, depriving narcoleptics of restorative rest and
exacerbating daytime drowsiness. Some feel as if they

have hardly slept at all.
Automatic behavior. Because of their profound
sleepiness, people with narcolepsy perform many routine tasks without being fully aware of what they are
doing. For example, one man washed and dried the
dishes and then stacked them in the refrigerator, but
had no recollection of doing so.
Treatments for narcolepsy
Treatment for narcolepsy is geared toward improving wakefulness during the day and preventing REMrelated symptoms.
Most people require stimulant medications such
as methylphenidate (Ritalin) or dextroamphetamine
(Dexedrine) to counter sleep attacks and drowsiness
(see Table 6). Because these medications have been
abused as recreational drugs and misused as diet pills,
drug enforcement agencies often require physicians
to provide extensive documentation when they prescribe them. Even with medication, however, people
are never as alert as they would be if they didnt have
this condition.
Modafinil (Provigil) and armodafinil (Nuvigil) are
once-a-day medications to promote wakefulness that
have a different mechanism of action. They dont cause
such side effects as euphoria or weight loss, so theres
less concern about misuse or abuse, but they arent as
potent as the older stimulants.
In most people, antidepressants that suppress
REM sleepsuch as fluoxetine (Prozac), sertraline
(Zoloft), paroxetine (Paxil), clomipramine (Anafranil), or venlafaxine (Effexor)can also prevent cataplexy and other REM-related symptoms.
Another medication for cataplexy is sodium oxybate (Xyrem), also known as gamma hydroxybutyrate
(GHB). This medication helps decrease the number of
cataplexy episodes and may improve nighttime sleep
and reduce daytime sleepiness as well. Because of its
chemical properties, it must be taken at bedtime and
again during the middle of the night. Xyrem is tightly
regulated because of its potential for misuse; it has been
associated with criminal acts such as date rape.
Improving Sleep
39
Disturbances of sleep timing
hen their internal clocks are disturbed, people

may long for sleep when they need to be awake
or may stay up until the wee hours of the morning
without feeling tired.
Delayed sleep phase syndrome
Almost everyone is programmed for a day that lasts

slightly longer than 24 hours, but night owls are less
sensitive to the environmental cues that help most people maintain the usual 24-hour cycle. Left to their own
devices, they would generally go to sleep and wake up
much later each day. Only by relying on external cues,
such as alarm clocks, do they manage to stay in sync
with a more conventional schedule. Night owls have
trouble getting anything done in the morning.
They may be able to gradually synchronize their
schedule with others by going to bed and getting up
at the same time every day. However, its easy for their
sleep patterns to go awry when they go on vacation
or retire. Night owls often find that a minor shift in
sleep/wake cyclessuch as the onset of daylight savings time, a coast-to-coast trip, or a weekend of latenight partiescan throw them off kilter unless they
force themselves to get up at the same time every day.
Resetting your internal clock

Exposure to bright light as directed by a sleep specialista technique known as light therapymay be useful in treating delayed sleep phase syndrome. Upon
awakening, patients typically sit for 30 minutes facing a specially manufactured box that emits bright
light with a minimal amount of ultraviolet light. Initial studies used white light, which contains the entire
spectrum of light wavelengths. More recent studies
suggest that blue light is the most potent part of the
spectrum for resetting the circadian clock.
Another option is to move your bedtime progressively later until youve shifted around the clock and
40
Improving Sleep
are back in sync. To do this, go to bed three hours later

each night. Once you have synchronized your schedule to match that of the other people around you, wake
yourself up at the same time each day.
A delayed sleep phase also can be reset in a single
weekend. This requires staying up all night on Friday and
all day Saturday, then going to bed around 10 p.m. On
Sunday, get up at 7 a.m. From then on, adhere closely to
the same bedtime and waking time seven days a week.
Melatonin may also have a role in treating delayed
sleep phase syndrome; taking 1 to 3 milligrams at your
desired bedtime may help advance your sleep schedule.
Advanced sleep phase syndrome
People whose body rhythm cycles are shifted much

earlier go to bed earlier, wake up in the early morning,
and eventually cant stay awake past early evening. This
condition, called advanced sleep phase syndrome, is
more common among older people. Treatments being
studied include bright light therapy in the evening,
which helps reset the bodys clock, and carefully timed
doses of melatonin.
Jet lag
Many people find that crossing several time zones

makes their internal clocks go haywire. In addition to
having headaches, stomach upset, and difficulty concentrating, they may suffer from fitful sleep.
Younger people usually adapt more quickly to
time changes than older people. It takes about a day to
adjust for every time zone crossed. Many people have
more difficulty traveling eastward, but older people
may have more symptoms traveling westward.
The standard way to handle jet lag is to try to sleep
only at night upon arrival and to get up early in the morning, although it may be difficult the first few days. You
can also gradually adjust your sleep time prior to leaving
(see Figure 8). This way your body can start adjusting to
the new time zone as soon as possible. Short-term use of
timed doses of melatonin or ramelteon to shift circadian
rhythms or over-the-counter or prescription sleep aids
to help you sleep at night also can be helpful.
Sunday insomnia
People often have trouble falling asleep on Sunday

nights. While anxiety about work or school on Monday
is a potential cause, often the most important factor is
weekend changes in sleep habits. When you stay up later
Friday night and sleep in Saturday morning, you are
primed to stay up even later Saturday night and sleep
in the next day. By Sunday evening, your bodys clock
is programmed to stay up late. People who have devel-
oped a pattern of Sunday insomnia may feel their anxiety mount as they anticipate a difficult night ahead.
The best way to avoid the Sunday blues is to maintain the same wake-up time and bedtime on the weekends as during weekdays. If this isnt possible and you
end up staying up later than usual on Friday and Saturday, the next best thing is to force yourself to get
up at your weekday wake-up time and take an early
afternoon nap on Saturday and Sunday. This way, you
maintain the same wake-up time while still compensating for your sleep deprivation.
Shift work
More than 20% of American workersincluding

health care workers, police officers, security guards,
Ways to avoid jet lag

Dont time-shift. On a brief trip just one
or two time zones away, it may be possible

to wake up, eat, and sleep on home time.
Schedule appointments for times when you
would be alert at home.
Gradually switch before the trip. For
several days before you leave, move mealtimes and bedtime incrementally closer to
the schedule of your destination. Even a
partial switch may make the trip easier.
Figure 8 Reset your biological clock

Day 1
Day 2
Day 3
9:30pm
9:00pm
Usual bedtime
10:00pm
Day 4
8:30pm
Switch as rapidly as possible upon
arrival. On a long trip, dont turn in until

its bedtime in the new time zone. For the
first day or two, spend as much time outdoors as possible to let daylight reset your
internal clock.
Use the sun. If you need to wake up
earlier in the new setting (flying west to

east), get out in the early morning sun. If
you need to wake up later (flying east to
west), expose yourself to late afternoon
sunlight.
Drink plenty of fluids, but not caf-
feine or alcohol. Caffeine and alcohol

promote dehydration, which worsens the
physical symptoms of jet lag. They can
also disturb sleep.
Traveling west to east

Help reset your biological clock when you travel through time zones. If youll
be traveling through several time zones, as when flying coast to coast, you
can gradually adjust your sleep time. For example, three days before you
plan to travel from the West Coast to the East Coast, go to bed half an hour
earlier than usual, and get up half an hour earlier the next morning. The next
night, go to bed an hour earlier than usual and get up an hour earlier. The
day before you travel, make it 90 minutes. By the fourth daythe day of
your tripyoull find it easier to adjust to your new time zone.
Improving Sleep
41
and transit workersare on the evening or night shift.

About 60% to 70% of shift workers experience sleep
disturbances. These people fall asleep on the job two
to five times more often than day-shift workers do.
Sleepiness can be catastrophic for people in these vital
roles. Sleep-deprived physicians, for example, make a
greater number of errors than their better-rested colleagues, and its common for fatigue to play a role in
overnight rail, plane, truck, and maritime accidents.
Shift workers sleep disruption can be eased somewhat by incorporating scheduled breaks, by rotating
shifts from day to evening to night rather than the
other way around, or by maintaining the same schedule seven days a week. Shift workers can also benefit
from practicing good sleep hygiene (see Tips for a
better nights sleep, page 14). Dark curtains or eyeshades can keep daylight out, and running a fan can
help block external noise. Shift workers need to enlist
the help of family members to get enough sleep while
maintaining a schedule at odds with the rest of the
world. The most successful shift workers are those
42
Improving Sleep
who block out time for sleep in advance and then are
vigilant about protecting their sleep time from outside
intrusions. Light therapy is sometimes recommended
to help people get used to a new schedule, as is the
short-term use of sleep medications.
Seasonal affective disorder
In some parts of North America, winter means less

exposure to sunlight. As the days get shorter, some
people find themselves depressed, sleepy, and drawn
to high-carbohydrate foods.
Researchers speculate that people who suffer
from this condition, called seasonal affective disorder
(SAD), produce too much melatonin (or are extra-sensitive to normal amounts of this drowsiness-inducing
hormone) and dont make enough serotonin, which
may induce the craving for carbohydrates. Exposure
to bright light in the morning for 30 minutes may alleviate the symptoms of SAD and help people wake up in
the mornings. Antidepressants can also be helpful.
Evaluation of sleep disturbances
lthough two-thirds of Americans have sleep problems, the vast majority of people with sleep disturbances suffer in silence. They enjoy life less, are less
productive, and endure more illnesses and accidents
at home, on the job, and on the road.
When to seek help
The American Academy of Sleep Medicine recommends seeking medical advice if sleep deprivation has
compromised your daytime functioning for more than
a month. Dont hesitate to ask for help when youre
sleeping badly following a death in the family or other
stressful event. A physician may suggest the shortterm use of a sedative to help you sleep at night and
thus cope better during the day and prevent development of a long-term sleep disorder.
Its not always easy for people to get evaluation and
treatment for a sleep problem. Doctors trained in the
United States receive just over three hours of instruction on this topic during four years of medical school.
According to a National Sleep Foundation survey, most
primary care physicians do not routinely ask their
patients about sleep. And while most of the physicians
who took part in the survey admitted they had limited
knowledge about sleep-related matters, more than half
did not consult with an expert in sleep medicine. So its
in your best interest to seek out the help you need.
Your sleep history

A sleep disturbance cannot be accurately diagnosed
unless your physician is familiar with your sleep habits and history. This information may be gleaned from
an interview or from written questionnaires that you
review and discuss with your doctor (see A sample
sleep history questionnaire, page 44, and Screening
for sleep apnea, page 29). A bedroom partner may
be able to help answer some of these questions and
should contribute to the discussion.
Some people are so used to sleep deprivation that

they dont realize theyre tired; instead, they may see
themselves as lazy, lethargic, or not very motivated.
Or they may not think it is unusual to fall asleep at a
movie or while sitting at dinner with friends. Someone
considered by family members to be a good napper,
able to drop off quickly and sleep through anything,
may actually be displaying signs of abnormal sleepiness. Your physician may ask how likely you are to
doze off in certain situations. The less appropriate the
circumstances (such as waiting in traffic while driving or having a conversation), the more dangerously
sleepy you are considered to be.
The psychiatric interview

Sleep disturbances, particularly insomnia, are often
related to psychological difficulties that respond well
to treatment once theyve been identified. Physicians
may screen problem sleepers for symptoms of depression, anxiety, childhood physical or sexual abuse, or
other psychological problems or traumatic experi-
Figure 9 Undergoing a sleep study
Polysomnography is commonly done in sleep labs to monitor

patients sleep. For this procedure, small electrodes placed on the
scalp and other parts of the body take readings during the night.
Lab staff examine the readings from a nearby control room.
Improving Sleep
43
ences (see Discovering the cause of sleeplessness,

page 45). If one of these conditions is diagnosed, your
primary care physician may refer you to a psychologist or psychiatrist for treatment.
Sleep laboratory evaluation
Most people with sleep problems dont need to visit a

sleep laboratory. Insomnia and circadian rhythm disorders, for example, can be diagnosed by a thorough
history and physical examination. However, when a
doctor suspects a sleep disorder such as narcolepsy,
periodic limb movement disorder, sleep apnea, or one
of the parasomnias, he or she may recommend formal
sleep testing.
Fees depend on the level of testing required. Some
people require a one-time consultation with a sleep
specialist, which may run a few hundred dollars. Staying overnight in a sleep laboratory costs between $800
and $1,500. Check with your insurance company in

advance because reimbursement varies and may
depend on your diagnosis.
The American Academy of Sleep Medicine has a
listing of more than 1,800 accredited sleep disorder
centers and more than 3,000 board-certified sleep specialists (see Resources, page 48). Some centers allow
you to make an appointment directly, while others
require a physician referral. The center will request
medical records and may send you a sleep questionnaire or diary to use before your visit. You may also
be asked to change your sleep habits in certain ways
before scheduling the visit. Sometimes these changes
alone correct the problem.
Overnight sleep tests

When you spend the night in a sleep laboratory, youll
wear your own nightclothes and you can use a pillow
from home. You can take your regular medications,
A sample sleep history questionnaire

Your physician may ask you some of the following questions during an evaluation for a sleep problem. You may find it helpful
to write down your answers to these questions and bring the completed questionnaire to the exam so you and your doctor can
discuss it.
What bothers you most about your sleep habits?
Do allergies or nasal congestion bother you at night?
How long have you had trouble sleeping, and what do you
Do you have physical aches and pains that interfere
think started the problem? Did it come on suddenly?

How would you describe your usual nights sleep?
What time do you go to bed, and when do you wake up?
What medications or drugs (including alcohol and nico-
tine) do you use? Have you ever taken sleep medications?

If so, which ones?
How long does it take you to fall asleep?
Do you often have indigestion at night?
Once youre asleep, do you sleep through the night or
Do you ever feel discomfort or a fidgety sensation in your
wake up frequently?
Whats your bedroom like?
What do you do in the few hours before bedtime?
Do you follow the same sleep pattern during the week
and on weekends? If not, how are weekends different?

How well do you sleep on the first few nights when youre
away from home? At home, do you sleep better in your

bedroom or in another room in the house?
Do you often feel sleepy during the day?
Do you fall asleep at inappropriate times or places?
Have you ever been in a car accident or had a close call
because you nodded off at the wheel?
44
with sleep?
Improving Sleep
legs and feet when you lie down? Do you have to get up
and walk around to relieve the feeling?
Do you kick or thrash around at night?
Do you ever have trouble breathing when you lie down,
or do you awaken because its hard to breathe?

Does your bed partner or roommate mention that you
snore loudly or gasp for air at night?

Do you ever awaken with a choking sensation or a sour
taste in your mouth?

Do you wake up with a headache or with cramps in
your legs?
How have you been feeling emotionally? Does your life
seem to be going as well as you would like?
but the clinicians will need to know what they are. The
lab usually provides a regular bed in a private room
with a bathroom attached. The room is kept as quiet
as possible.
After a technician sets up the sleep-monitoring
equipment, youll be left alone to relax until bedtime.
Throughout the night, laboratory staff will monitor
the instruments in a nearby control room. Procedures
used may include polysomnography, audio and video
recording, and daytime sleep tests.
Polysomnography. In this procedure, small waferthin electrodes and other sensors are pasted on specific body sites to take a variety of readings during the
night. They may be placed on your scalp to track brain
waves; under your chin to measure fluctuations in
muscle tension (called an electromyogram, or EMG);
near your eyes to measure eye movements; near your
nostrils to measure airflow; on your earlobe or finger
to measure the amount of oxygen in your blood (using
a device called an oximeter); on your chest or back to
record heart rate and rhythm; on your legs to record
twitches or jerks; and over your rib muscles or around
the rib cage and abdomen to monitor breathing (see
Figure 9).
Readings are collected on a single printout (called
a polysomnogram) and analyzed by a technician and
physician. If a breathing problem is detected early on,
you may be awakened and given treatment, such as
PAP, during the second half of the night. This allows
the sleep experts to monitor how well the treatment
works for you. Sometimes this process requires two
nights. A standard polysomnogram cannot diagnose
sleep-related epilepsy. If your doctor suspects that you
have a seizure disorder, you may undergo a full electroencephalogram (EEG) during the night.
Audio and video recording. Audio equipment may
be used to record snoring, talking during sleep, or
other sounds. A video may also be taken to compare
with the polysomnogram. This may show, for example, that you snore only when in a certain position.
Signs of movement disorders (such as periodic limb
movement disorder) or parasomnias will probably be
apparent on the video.
Daytime sleep tests. Daytime sleep tests may be
administered after a night in the sleep lab. The multiwww.h e a l t h . h a r v a r d . e d u
Discovering the cause of sleeplessness

Are you depressed?
Yes
No
1. I feel downhearted, blue, and sad.

2. I dont enjoy the things I used to.
3. I have felt so low Ive thought of suicide.
4. I feel that Im not useful or needed.
5. I notice that Im losing/gaining weight.
6. I have trouble sleeping through the night.
7. I am restless and cant keep still.
8. My mind isnt as clear as it used to be.
9. I get tired for no reason.
10. I feel hopeless about the future.
You may be suffering from depression if you answered yes to at
least five of these questions, you answered yes to either question
1 or question 2, and these symptoms have persisted for at least
two weeks. You should seek professional help immediately if you
answered yes to question 3.
Are you anxious?
Yes
No
1. Do you feel upset or tense, maybe without

even knowing why?
2. Does your heart often race uncontrollably?
3. Are your hands often sweaty, clammy, or
extremely cold?
4. Do you often have a lump in your throat?
5. Do you have difficulty slowing down or relaxing?
6. Do you often feel insecure or anxious?
7. Do you often feel ill at ease?
8. Do you often feel tired without any reason?
9. Do you often worry about things youve said
that might have hurt somebodys feelings?
10. Do you tend to worry, even over things that
you realize dont matter?
11. Are you presently worrying over a possible
misfortune?
12. Do you often feel nervous, jittery, or high-strung?
13. Are you more apprehensive about the future
than other people are?
If you answered yes to five or more of these questions, you are
probably more anxious or tense than other people, and you may
need to seek professional help.
Reprinted with permission from No More Sleepless Nights by Peter Hauri,
Ph.D., and Shirley Linde, Ph.D.
Improving Sleep
45
How sleepy are you?

Sleep specialists often use this measure, called the
Epworth Sleepiness Scale, to gauge a patients level of
daytime sleepiness.
Imagine yourself in the following situations, and then select
your likelihood of dozing using the 03 scale below. Add up
these numbers. If you score 10 points or more, consider seeing
a physician for an evaluation.
Scale:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situation
Score
Sitting and reading

Watching TV
Sitting inactive in a public place, like a theater or
meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (when youve had no
alcohol)
In a car while stopped in traffic
TOTAL
ple sleep latency test measures how long it takes you to

fall asleep while lying down in a quiet room and what
stages of sleep occur during a brief nap. The procedure
is usually repeated four or more times during the day
at two-hour intervals. This test measures sleepiness
and looks for signs of narcolepsy. Falling asleep within
five minutes each time indicates extreme sleepiness.
In the maintenance of wakefulness test, which is
less commonly used, youre given the opposite instructions: try to stay awake. This ability is also affected by
the degree of sleepiness. People are sometimes given
both tests at different times.
Home-based tests
For people who, based on their symptoms, probably have sleep apnea (see page 28) and who have no
46
Improving Sleep
other significant other medical problems, home sleep

monitoring may be helpful. Portable home recording devices also may be useful when polysomnography is not available and the persons symptoms
suggest a need for immediate treatment, or when a
patient is bedridden or medically unstable and cannot be moved. Home-based tests may also be used
when a physician wishes to evaluate the effectiveness
of treatment.
Apnea detectors. To detect breathing disturbances
during sleep, a patient can be equipped with apnea
detectors that measure heart rate, snoring sounds,
body position, nasal airflow, and the amount of oxygen in the blood. Although these devices have been
used to estimate how many people suffer from breathing disturbances, the information they provide isnt
as accurate as a sleep lab evaluation. Unlike in a sleep
lab, there is no technician to monitor the device and
patient, and there is a higher rate of problems associated with the home-based devices. As a result, the
information may not be sufficient to diagnose and
devise a treatment plan.
Wrist actigraphy. A wristwatch-sized monitoring device that automatically records arm or leg
movements can be used to track periods of sleep
and wakefulness at night. Although it cannot determine the stage of sleep, it can help clarify ambiguous
aspects of a sleep diarysuch as entries reporting
long hours of sleep but exhaustion the next day
or assess the effectiveness of medical treatment. The
actigraphy device may reveal that brief awakenings
during the night are unknowingly disturbing sleep.
In some studies, wrist actigraphy accurately determined whether a person was asleep almost 90% of
the time.
The American Academy of Sleep Medicine recommends polysomnography, done in a sleep lab, as the
best method for diagnosing sleep apnea and determining its severity. Portable home devices can miss
mild apnea and other sleep disruptions, and they dont
provide the sleep stage information needed to rule out
other sleep disturbances. Accordingly, they should
only be used when the patients physician is familiar with the devices benefits and limitations and has
experience interpreting the results.
The benefits of good sleep
y now, you should have a solid understanding of the

various sleep problems and their consequences. Its
worth taking a moment to look at the flip side: the benefits of routinely getting a good nights rest. Here, the
encouraging news is that if you successfully conquer
whatever is preventing you from sleeping soundly
either on your own or with a sleep specialists assistanceyou have a lot to look forward to.
Research documents the improvements that can
come with treatment:
People with chronic insomnia who participated in
six 50-minute sessions of cognitive behavioral therapy (CBT) improved their sleep efficiency (the percentage of time spent asleep while in bed) more than
people who took a prescription sleeping pill. The
researchers also showed that people who underwent
CBT increased their total time in slow-wave (deep)
sleep.
People with sleep apnea who used CPAP for one year
reported quality-of-life improvements (such as better energy, mental health, and social satisfaction)
that brought them to the same level as the general
population.
People with narcolepsy treated with modafinil for six
weeks reported significant improvements in energy
and a significant reduction in daytime fatigue.
Patients treated by sleep specialists gain a number
of benefits. Often, people with sleep disorders function without sufficient sleep for so long that they come
to accept their constant fatigue as normal and assume
they will always feel tired. After a few weeks of healthy
sleep, some patients report feeling like a whole new
person, with newfound energy and an improved out-
look on life. In some cases, such people are able to

accomplish things theyve always put off attempting,
such as completing college or getting an advanced
degree, switching careers, or finding a life partner.
So if youre struggling to get a good nights rest,
there is much cause for optimism. While theres no
guarantee youll always get eight hours of uninterrupted sleep, with proper treatment you can reasonably expect improvements in both your nighttime
sleep and your overall quality of life.
Sleep review
For such a natural and necessary thing, sleep is the source
of much anxiety. Here is a review of the basic steps to follow if youre having trouble maintaining normal, healthy
sleep patterns:
Practice good sleep hygiene, such as making sure your
bedroom is sleep-friendly, avoiding caffeine and alcohol before bedtime, and going to bed and waking up at
the same time every day (see Tips for a better nights
sleep, page 14).
Make sure youre getting proper treatment for any
underlying illnesses, such as cardiovascular disease or

diabetes, that may interfere with sleep (see Medical
conditions and sleep problems, page 16).
Keep a sleep diary to look for patterns you may not be
aware of and to track progress.

Make sure your primary care physician is aware of any
over-the-counter or alternative medicines you take to

help you sleep, and follow your doctors recommendations about taking prescription sleep aids (see Prescription medications for insomnia, page 22).
If sleep problems persist despite your own efforts, con-
sider seeing a sleep specialist for a thorough sleep evaluation (see Evaluation of sleep disturbances, page 43).
Improving Sleep
47
Resources
Organizations
American Academy of Sleep Medicine
1 Westbrook Corporate Center, Suite 920
Westchester, IL 60154
708-492-0930
www.aasmnet.org
www.sleepeducation.com
Dedicated to the advancement of sleep medicine and related
research, this organization also provides the public with information on sleep disorders as well as contact information for accredited sleep centers.
American Sleep Apnea Association
6856 Eastern Ave. NW, Suite 203
Washington, DC 20012
202-293-3650
www.sleepapnea.org
This nonprofit organization provides information on sleep apnea
via brochures, a newsletter, and videos. It also operates a network
of support groups throughout the country.
Narcolepsy Network
110 Ripple Lane
North Kingston, RI 02852
888-292-6522 (toll-free)
www.narcolepsynetwork.org
This organization offers educational materials on narcolepsy, as
well help in finding support groups.
National Center on Sleep Disorders Research
National Heart, Lung, and Blood Institute, NIH
6701 Rockledge Drive
Bethesda, MD 20892
301-435-0199
www.nhlbi.nih.gov/about/ncsdr
This federal center, part of the National Institutes of Health,
coordinates government-supported sleep research, training, and
education and offers a number of free publications about sleep
disorders.
National Sleep Foundation
1522 K St. NW, Suite 500
Washington, DC 20005
202-347-3471
www.sleepfoundation.org
Restless Legs Syndrome Foundation, Inc.

1610 14th St. NW, Suite 300
Rochester, MN 55901
507-287-6465
www.rls.org
This nonprofit foundation distributes brochures and provides
information on restless legs syndrome. It also publishes the quarterly newsletter NightWalkers and maintains a list of support
groups located throughout the country.
Web sites
Conquering Insomnia Program
www.cbtforinsomnia.com
This cognitive behavior therapy program, developed at Harvard
Medical School and the University of Massachusetts Medical
Center, is available for purchase as either an online program or in
CD format.
Sleep and Health Education Program
http://healthysleep.med.harvard.edu
Created by Harvard Medical Schools Division of Sleep Medicine
and the WGBH Educational Foundation, this site aims to help the
general public understand sleep and to get the sleep they need.
Sleep Healthy Using the Internet
www.shuti.net
This interactive Web-based program, developed at the University
of Virginia Center for Behavioral Medicine Research, provides
cognitive behavior therapy for insomnia. At this writing, the program is available only to participants in a research study.
Book
The Harvard Medical School Guide to a Good Nights Sleep
Lawrence J. Epstein, M.D., and Steven Mardon
(McGraw-Hill, 2007)
This book, co-written by the medical editor of this report, covers
sleep physiology; sleep disorders such as insomnia, sleep apnea,
and narcolepsy; sleep medications; childhood sleep problems; and
coping with jet lag. The book includes a six-step plan for getting
a good nights sleep.
This nonprofit foundation helps consumers locate sleep centers

and provides information on a variety of sleep topics.
48
Improving Sleep
Glossary
advanced sleep phase syndrome: A daily sleep/wake
rhythm in which the onset of sleep and the time of awakening are earlier than desired; the person wakes up earlier and
wants to retire earlier each day.
apnea: Cessation of breathing during sleep, lasting at least 10
seconds and associated with a fall in blood oxygen or arousal
from sleep.
narcolepsy: A sleep disorder marked by excessive sleepiness

or sudden sleep attacks.
obstructive sleep apnea: Disordered breathing during sleep,
resulting from blockage of the airway.
parasomnias: Episodic disruptive behaviors occurring during
sleep, indicating abnormal or partial arousal.
cataplexy: Sudden paralysis of some or all muscles, brought

on by laughter, anger, or strong emotions; a hallmark of
narcolepsy.
periodic limb movement disorder (PLMD): Syndrome characterized by periodic jerking of the limbs during sleep and
daytime sleepiness.
central sleep apnea: Sleep apnea caused when respiratory

control centers in the brain fail to activate breathing muscles.
polysomnography: Simultaneous recording of brain waves

and other measures of physiological functioning to assess
sleep.
circadian rhythm: The innate biological clock that regulates

sleep and waking and controls the daily ups and downs of
physiologic processes, including body temperature, blood
pressure, and the release of hormones.
deep sleep: See slow-wave sleep.
delayed sleep phase syndrome: A daily sleep/wake rhythm
in which the onset of sleep and wake times are later than
desired; the person tends to go to bed later and get up later
each day.
electroencephalogram (EEG): A recording of brain waves
obtained by attaching flat metal discs (electrodes) to the
scalp; it shows changes in brain waves.
hypnagogic hallucinations: Often terrifying dreamlike
sounds or images occurring just before sleep; a symptom of
narcolepsy that can be mistaken for psychosis.
hypnogram: A diagram that summarizes the stages of sleep
recorded in the sleep laboratory.
insomnia: A condition marked by trouble falling asleep or
staying asleep, or sleep that is nonrestorative.
positive airway pressure (PAP): A treatment for sleep apnea

in which a continuous stream of air is delivered through a
mask worn over the nose to keep the sleepers airway open.
quiet sleep: All sleep except REM sleep. In the quiet phase
of sleep, thinking and most physiological activities slow, but
movement can still occur. Also called non-REM sleep.
rapid eye movement (REM) sleep: A period of intense brain
activity often associated with dreams; named for the rapid eye
movements that occur during this time. Also called dreaming
sleep.
restless legs syndrome (RLS): Achy or unpleasant feelings
in the legs associated with a need to move. Most prominent
at night, making it hard to fall asleep or stay asleep.
sleep architecture: The pattern made when sleep stages are
charted on a hypnogram.
somnambulism: Sleepwalking.
somniloquy: Talking in ones sleep.
melatonin: A hormone that helps regulate circadian rhythms,

produced in a predictable daily rhythm by the pineal gland.
Improving Sleep
49
Order this report

and other publications from
Harvard Medical School
online
phone
877- 649-9457 (toll-free)

P.O. Box 9306
Big Sandy, TX 75755-9306
mail
bulk rate 203-653-6270
tphillips@staywell.com
877-649-9457 (toll-free)
Other publications from Harvard Medical School

Special Health Reports Harvard Medical School publishes in-depth
reports on a wide range of health topics, including:
Addiction
Alcohol
Allergies
Alzheimers Disease
Anxiety and Phobias
Arthritis
Back Pain
Caregivers
Cholesterol
Depression
Diabetes
Diabetes & Food
Energy/Fatigue
Erectile Dysfunction
Exercise
Eye Disease
Foot Care
Grief and Loss
Hair Loss
Hands
Headache
Hearing Loss
Heart Disease
Heart Disease & Diet
High Blood Pressure
Incontinence
Knees and Hips
Living Independently
Living Longer
Memory
Neck & Shoulder Pain
Nutrition
Osteoporosis
Positive Psychology
Prostate Disease
Sensitive Gut
Sexuality
Skin Care
Sleep
Strength Training
Stress Management
Stroke
Thyroid Disease
Virus
Vitamins & Minerals
Weight Loss
Workout Workbook
Periodicals Monthly Newsletters and Quarterlies including:

Harvard Health Letter
Harvard Womens Health Watch
Harvard Mens Health Watch
Harvard Heart Letter

Harvard Mental Health Letter
Perspectives on Prostate Disease
ISBN 978-1-935555-18-6
SU11000
IS10

HARVARD MEDICAL Improving Sleep - A Guide To A Good Nights Rest PDF

Transféré par

Informations du document

Description originale:

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

HARVARD MEDICAL Improving Sleep - A Guide To A Good Nights Rest PDF

Transféré par

Droits d'auteur :

Formats disponibles

A Harvard Medical School Special Health Report

Harvard Health Publications

Heres what you CAN do

Heres what you CANT do

Routinely copy and distribute portions.

For more information

Licensing and Corporate Sales

Telephone: 888-456-1222 x31110 (toll-free)

Sleep throughout life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

special bonus section:

General ways to improve sleep. . . . . . . . . . . . . . . . . . . . . 14

Medical conditions and sleep problems. . . . . . . . . . . . . . 16

Breathing disorders in sleep. . . . . . . . . . . . . . . . . . . . . . . 27

Harvard Health Publications

Movement disorders and parasomnias. . . . . . . . . . . . . . . 33

For the latest information and most up-to-date publication

Ordering Special Health Reports

Disturbances of sleep timing. . . . . . . . . . . . . . . . . . . . . . . 40

For multiple-copy discount rates, please write or call:

Delayed sleep phase syndrome. . . . . . . . . . . . . . . . . . . . . . . .

For corporate sales and licensing, please e-mail:

Evaluation of sleep disturbances . . . . . . . . . . . . . . . . . . . 43

Harvard Medical School publishes Special Health Reports

When to seek help. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

The benefits of good sleep . . . . . . . . . . . . . . . . . . . . . . . . 47

Lawrence Epstein, M.D.

or centuries, scientists scrutinized minute aspects

Figure 1 EEG brain wave patterns during sleep

REM or dreaming sleep

These brain waves, taken by electroencephalogram, are used by

Using electrodes to monitor sleepers eye movements,

Sleep specialists have called non-REM or quiet sleep

lack hypocretin, and they consequently flip back and

Three stages of quiet sleep

and muscle repair. Researchers have also detected

Dreaming (REM) sleep

Dreaming occurs during REM sleep, which has been

Your internal clock

Figure 2 Sleep architecture

When experts chart sleep stages on a hypnogram, the different

explain why students who stay up all night cramming

During the night, a normal sleeper moves between

Certain brain structures and chemicals produce the states

Figure 3 The sleep/wake control center

The pacemaker-like mechanism in your brain that regulates the

Mechanisms of your sleep clock

a predictable daily rhythm by the pineal gland, which is

Your clocks hour hand

Sleep throughout life

A gene that controls sleep length

sleep decrease, and you awaken more often during

For an adult to sleep like a baby is not only unrealistic

In contrast, adolescents are known for their daytime

start earlier than elementary schools. Other research

Getting a good nights

During young adulthood, sleep patterns usually seem

products), which contribute to heartburn.

head of your bed by placing blocks under the bedposts.

trips to the bathroom.

Women who arent pregnant may experience

Table 1 Sleep changes during adulthood

Time to fall asleep

Avoid eating foods that contribute to heartburn.